Care Home: Hazelmere House Care Home

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What the care home does well People had had an assessment of their needs completed before they were admitted in to the home to make sure that they would be looked after properly at the home. Care plans had been developed in all cases to show how care needs should be met. The home had an activities coordinator and a variety of activities were provided although this had reduced since the last inspection. Visitors to the home said that they are always made to feel welcome. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.2 The people who lived in the home enjoyed the meals provided. Comments included ‘the food is very good’, ‘the foods fine’ and ‘food ok’. Complaints were well managed and people felt comfortable raising any issues but they did not have any complaints. Staff received training relevant to their role and staff turnover was low. What has improved since the last inspection? The assessments were now more detailed and this ensured that that all information about people’s needs and preferences was available to staff. The care packages had been reviewed regularly to ensure that people’s needs continued to be able to be met in the home. The heating system had been repaired and the home was warm throughout. Receipts for purchases on behalf of the people living in the home were held to ensure a full audit trail of money held in the home. The fire systems had been checked to ensure they were in full working order. Fire alarms had been checked at least weekly and emergency lighting had been checked at least monthly. What the care home could do better: The care plans and records of care provided could be more detailed to ensure that that all the information about how people’s should be met is available to staff. There was a marked deterioration in the decoration, cleanliness and odour control in communal areas in the home. A refurbishment plan should be developed to show how the decoration in communal areas is to be improved. The carpets in communal areas must be cleaned or replaced where stainingHazelmere House Care HomeDS0000002849.V378236.R01.S.doc Version 5.2 cannot be removed or unpleasant odours controlled. This is to ensure a more pleasant environment for people living in the home. There may insufficient moving and handling equipment in the home with the provision of only one hoist. The hoist which was out of commission at the time of the inspection must be repaired or additional moving and handling aids provided. An effective quality assurance and quality monitoring system must be implemented to ensure that the service is run in the best interests of the people living in the home. Staff must be provided with supervision at least six times per year to ensure staff are supported to in their role. . Key inspection report CARE HOMES FOR OLDER PEOPLE Hazelmere House Care Home 2-4 Welholme Avenue Grimsby North East Lincs DN32 0HP Lead Inspector Kate Emmerson Key Unannounced Inspection 27 October 2009 09:30 DS0000002849.V378236.R01.S.do c Version 5.3 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelmere House Care Home Address 2-4 Welholme Avenue Grimsby North East Lincs DN32 0HP Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01472 240399 01472 362955 Homearch Limited Situation Vacant Care Home 30 Category(ies) of Dementia (8), Old age, not falling within any registration, with number other category (22) of places Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th November 2008 Brief Description of the Service: Hazelmere House is situated in a residential area of Grimsby. It is within walking distance of shops. It is also on a public transport route. The home is able to support and care for up to thirty people over the age of sixty-five, six of whom can have the category of Dementia. The home is over two floors accessed by a passenger lift. An extension was completed several years ago as part of an overall refurbishment programme that has brought the standard of accommodation up to high specifications. There are twenty-eight single rooms and one shared room, and all have the benefit of en-suite facilities. There are two assisted bathrooms and a large shower room downstairs and a further assisted bathroom upstairs. The home has two lounges and a large dining room with an extra seating area at one end. There are mature gardens to the rear of the building with a patio area and lawn. There are facilities for car parking at the front and side of the building. The current fees for services provided through the home ranges between £385 and £412 per week. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes The site visit was unannounced and took place on 27 October 2009. The manager was in attendance throughout the inspection. We examined records held in the home including care files, staff recruitment and training files and health and safety records. We also spoke to some of the people living in the home and their visitors to gain their opinion of the care they received. We also spoke to some of the staff on duty about the care provided in the home and the training and support they received. An Annual Quality Assurance Assessment (AQAA) had been completed and returned to the Commission before the inspection took place. This provided us with a wide variety of information about the service and included improvements they had made since the last inspection We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations – but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: People had had an assessment of their needs completed before they were admitted in to the home to make sure that they would be looked after properly at the home. Care plans had been developed in all cases to show how care needs should be met. The home had an activities coordinator and a variety of activities were provided although this had reduced since the last inspection. Visitors to the home said that they are always made to feel welcome. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.2 Page 6 The people who lived in the home enjoyed the meals provided. Comments included ‘the food is very good’, ‘the foods fine’ and ‘food ok’. Complaints were well managed and people felt comfortable raising any issues but they did not have any complaints. Staff received training relevant to their role and staff turnover was low. What has improved since the last inspection? What they could do better: The care plans and records of care provided could be more detailed to ensure that that all the information about how people’s should be met is available to staff. There was a marked deterioration in the decoration, cleanliness and odour control in communal areas in the home. A refurbishment plan should be developed to show how the decoration in communal areas is to be improved. The carpets in communal areas must be cleaned or replaced where staining Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.2 Page 7 cannot be removed or unpleasant odours controlled. This is to ensure a more pleasant environment for people living in the home. There may insufficient moving and handling equipment in the home with the provision of only one hoist. The hoist which was out of commission at the time of the inspection must be repaired or additional moving and handling aids provided. An effective quality assurance and quality monitoring system must be implemented to ensure that the service is run in the best interests of the people living in the home. Staff must be provided with supervision at least six times per year to ensure staff are supported to in their role. . If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People’s needs were assessed and recorded prior to admission to the home. EVIDENCE: We examined four care files of people living at the home. The care files had been renewed since the last inspection and where people had been in the home for some time their original assessment had been archived. The care files contained detailed care plans which identified their assessed needs. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 10 A care file for a person more recently admitted to the home contained an assessment of needs which had been completed prior to admission. A detailed care plan had been developed from this. Assessments were a combination of the home’s pre-admission information and, where people’s care was funded through the local authority, care management assessments. The assessments covered aspects of the individual’s health and physical and social care needs and associated risks. The assessments were used to determine whether the home could meet people’s needs and people were informed in writing of the outcome of this process. People living in the home stated that they had been given the opportunity to visit the home before they made a decision to move there on a more permanent basis. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A full record of the care required or provided had not always been maintained. This means that people may not receive all the care required. However there was no evidence that people’s needs were not being met on the day of inspection and staff were knowledgeable about peoples care needs. Medication was well managed. People felt their privacy and dignity was promoted. EVIDENCE: All of the care files observed included care plans describing how people’s individual needs must be met. People funded through care management or health authorities had these agencies care plans held in their in their files. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 12 A new care plan format had been developed and implemented since the last inspection. Care plans were reasonably detailed and there was some evidence of updating. However there was a lack of consistency in the process of evaluation of care plans and recording health professional instructions. The care plans did not always record up to date information about the care required to meet people’s needs. The care plans had been evaluated monthly to ensure that they remained current but information from risk assessments and monitoring records had not always been taken into account during this process. For example, in one case a nutritional risk assessment recorded that a person required greater support due to weight loss but the care plan evaluation recorded no change and the care plan had not been updated. Care files demonstrated that, when people had health care needs, appropriate healthcare professionals including GP’s and community nurses were consulted. However care instructions prescribed following consultation, although recorded in the professional visit records, had not always been added to the plan of care. Daily records of care did not always provide evidence of the care and support provided to people or the status of the person’s health and wellbeing. The records mainly consisted of entries such as ‘no change’. Additional records to show the dietary and fluid intake and support for pressure relief had been maintained. Some of the new care plans did not show evidence that they had been agreed with the person receiving the care or their representative. The manager stated that she had been monitoring the care plans through regular monthly audits to improve consistency. However the evidence to support this was not robust consisting merely of a tick against a name. The manager was advised to complete detailed audits and provide clear written instructions for improvement to the care staff. The staff that administered prescribed medication had received accredited medication training and staff competency in this role was assessed. Medications, including controlled drugs, held in the home were appropriately stored and clear records were held. The medication administration records included a photograph of the person to ensure that all staff were clear whom the medication was intended for. Observation of staff interaction with people living in the home and conversations with people living in the home evidenced that people’s privacy and dignity was promoted. They stated that they could choose how to dress Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 13 and where to take their meals. They said staff knocked on the door before entering their bedroom and ensured that privacy was maintained when they were assisted with personal care. At the last inspection it was noted that a window in one of the bathrooms did not have adequate blinds/curtains to ensure the privacy and dignity of people using this area. A blind had since been fitted. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): All of the above Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People said they were enabled to maintain and develop their personal lifestyles at the home. However there had been a reduction of staffing levels and activities since the last inspection which had some impact on people daily routines. The majority of people who lived in the home enjoyed the food provided at the home. EVIDENCE: People indicated that the routines in the home met their individual needs and they enjoyed living at the home. Comments included ‘I can go to bed and get up when I want’ and ‘it’s marvellous’. However an entry in a diary record would not support this in one case. It was recorded that if someone wished to go to bed between 8pm and 9pm they couldn’t as there was only two staff on duty Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 15 and one was not able to assist with moving and handling. (See standard 27 regarding staffing levels) The manager stated that the home’s activity co-ordinator had left her post and the activity coordinators hours had been decreased from twenty-five hours to six hours per week. A member of the care staff was now covering these hours and arranging activities in the home. Records to evidence the activities provided in the home had been maintained since the last inspection. These showed a variety of activities was provided such as bingo, dominoes, one to one chats and monthly reminiscence meetings with an outside provider. There were posters around the home advertising some of the forth-coming activities. People living in the home had noticed a reduction in the activities provided. Comments included ‘there is plenty to do’, ‘not really a lot of entertainment’ and ‘no activities much now, used to go out a bit’. The visitors to the home said they were made to feel welcome by the staff and the management and that they were usually offered refreshments when they visited. We observed the lunch being served and spoke with several of the people living in the home about the meals provided. The mealtime was relaxed and individuals were given time to eat their meals. Where people required support this assistance was provided in a manner that maintained people’s dignity. The meals were well presented and the majority of those spoken with were very complimentary about the food. Comments included ‘the food is very good’, ‘the foods fine’, ‘food ok’ and ‘the foods awful’ (no detail could be given by this person as to why it was awful). Drinks were readily accessible in communal areas. The day’s menu was written on a white board close to the communal areas. The menu indicated that there was a choice offered at each meal. The kitchen was well maintained and was very clean. The home had achieved the best score available, with five stars having been awarded, in a recent kitchen assessment by environmental health. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had appropriate policies and procedures to support any complaints or allegations that were received. EVIDENCE: Complaints policies and procedures were in place and were displayed in the home. The home had recorded two complaints since the last inspection and these related to issues regarding boundary trees. These had been resolved and records of the complaints and responses were maintained. No complaints had been received by the Commission in respect of the service. People spoken with at the home said they would feel comfortable to speak to staff or the manager if they were unhappy with anything at the home but they did not have any complaints. Comments included ‘can’t crumble, I am satisfied’, ‘I enjoy living here’ and ‘I have no problems’. All of the staff spoken with were aware of the policies and procedures and what amounted to an allegation of any abuse. All of the staff had had training in Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 17 safeguarding vulnerable adults and refresher training had been arranged with the local authority. Prior to the inspection an investigation had been undertaken by the local authority in relation to an allegation of abuse at the home. The manager had taken appropriate action to safeguard people in the home but at the time of writing the local authority had not confirmed the outcome of the investigation with the manager or the Commission. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19, 22, 25 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The environment was suitable to the needs of the people living in the home however there was a marked deterioration in the decoration, cleanliness and odour control in communal areas in the home. There may insufficient moving and handling equipment in the home with the provision of only one hoist. EVIDENCE: A tour of the building was undertaken. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 19 The front hall and one bedroom had been redecorated since the last inspection. The gardens had been attended to and were now a much more pleasant space for people living in the home. There was a marked deterioration in the decoration, cleanliness and odour control in communal areas in the home. Carpets in the lounge and hallways were worn and stained. This may be due, in part, to a reduction in the domestic staffing hours. Care staff are now undertaking cleaning duties especially at weekends. A visitor commented ‘it could do with a bit of doing up’. People’s bedrooms, toilets and bathrooms were all very clean and tidy. The ground floor shower room had been cleared of stored items. The blind in one bathroom had been replaced to protect people’s privacy and dignity. The laundry was well organised and the washing machines were programmable to sluicing and disinfection standards. The care staff spoken with stated that they had only one hoist working in the building as the other had been out of commission for some time. They said that they were able to care for people adequately with only one hoist but that it was very labour intensive. This was because five people required assistance with this equipment, the majority of who were accommodated in first floor rooms requiring the hoist to be moved between floors via the lift. Not all the people who required assistance could state whether this affected their care, for example whether they had to wait for care to be provided if the equipment was in use elsewhere. (See also standard 27) The lighting at Hazelmere was domestic in character and the radiators had low temperature surfaces to ensure the safety of the people living in the home. Problems with the heating system noted at the last inspection had been addressed. One person said ‘my bedroom is lovely and warm’ and a visitor said ‘it’s always nice and warm’. Staff had received training in infection control. Policies and procedures were in place and staff confirmed that they had all the equipment necessary to support good practice in this area. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): All of the above. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff were not always provided in sufficient numbers to meet peoples individual needs in a timely manner. Staff had received a wide variety training in their role. EVIDENCE: There was no evidence that the dependency of the people accommodated was used to calculate the number of staff required on duty at the home at any time as per the residential forum guidelines. The manager stated that the head office determined the numbers of staff on duty; she had no access to the residential forum calculator tool. Following the inspection we used the residential forum to calculate the care staff hours based on the dependency ratings provided by the manager. This showed that the home should be providing 459.48 hours of care per week. The home was providing 342 hours per week. These figures were provided to the manager following the inspection. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 21 Staffing was arranged to provide additional staff at busier times of the day. However there were indications that staffing levels were not always sufficient to meet people’s individual needs. Whilst people spoken with stated that they could get up and go to bed when they wished, diary records in one case showed this was not always the case. It was recorded in a care file that if someone had wished to go to bed between 8pm and 9pm they couldn’t as there was only two staff on duty and one was not able to assist with moving and handling. This had caused this person to exhibit some challenging behaviour towards the staff. Staff also stated that as there was only one hoist in the home their work load was increased substantially transferring the hoist between floors via the lift to assist people. This should be taken into account when calculating staffing levels. Generally people living in the home were positive about the staff group. Comments included ‘the staff are excellent’, ‘the staff are very nice’, ‘you can’t fault the staff’, ‘carers – some good, some abrupt and rough’, ‘staff are very good, very nice, some like to be a bit bossy but I am treated with respect’. The manager stated that there had been no new staff employed in the home since July 2007, which was prior to the current responsible individual and manager taking up post. Information provided to the Commission prior to the inspection stated that two staff had left since the last inspection. The staff training and personnel files for three of the staff that worked at the home were examined. All of their personnel files showed that they had received the security vetting appropriate to their role. Training records showed that staff had received induction and foundation training that meets the requirements of the Sector Skills council workforce training targets. There was evidence that staff had completed a wide range of training including refresher training in moving and handling, safeguarding vulnerable adults and fire safety. Information provided to the Commission stated that staff were encouraged to complete relevant NVQ training and twelve of the sixteen staff had achieved at least level 2. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. An experienced manager was in place but she had not completed the process to be the registered manager of the home at the time of the inspection. The company conducted basic quality monitoring but there was no evidence that people living in the home had been consulted. Whilst staff felt supported they had not received the required levels of formal supervision. Management of health and safety in the home had improved. EVIDENCE: Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 23 The acting manager, Lorraine Willis, had taken up post in October 2008. She had previously been the deputy manager of the home and stated she was working towards NVQ 3 in care and was a qualified moving and handling trainer. She stated that she was well supported by the senior company managers who visited the home regularly. She had started the process of applying to be the registered manager. There was some basic quality monitoring in the service. The manager provided evidence that she was completing regular quality monitoring audits of care plans, people’s weight, incidence of pressure sores and accidents. However the audit of the care plans was not sufficiently robust to ensure that care plans were always up to date. (See standard seven) She stated that people using the service were surveyed about the quality of the service directly by head office. She had not been made aware of the outcomes of these surveys and there was no evidence of any feed back to people using the service. The manager stated that all the homes accounts were dealt with directly by head office. People using the service were invoiced directly by head office for the fees and any additional costs. There had been little significant development or refurbishment of the home since the last inspection and there had been a reduction in staffing across the home. A business development plan and refurbishment plan was not held at the home. The manager stated that refurbishment of the communal areas was due to commence in the near future. The manager stated that only two people had money held in safekeeping by the home. The accounts were well maintained and balanced with the money held. Records and discussions with staff confirmed that staff supervision had not been maintained at the frequency required to meet the standards. In two staff files examined only two sessions of supervision had been completed in 2009. An appraisal for both staff had been completed as part of one of these supervisions. Staff stated that they felt supported by the manager. There was improvement in the management of health and safety in the home. All the moving and handling equipment had been serviced on a regular basis except for one hoist which was out of commission due to repairs being required. This had been waiting for repair since May 2009 due to an outstanding invoice with the service company and left the home with one working hoist. The staff stated that while care was able to be provided it was a very labour intensive procedure. There had been improvements in the management of fire safety in the home and fire safety checks had been maintained. Records showed the fire alarm Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 24 had been tested weekly and the emergency lights had been checked monthly. The home had up dated the fire risk assessment in December 2008. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X 2 X X 2 2 STAFFING Standard No Score 27 2 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 2 3 2 X 3 Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 26 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7OP7 OP8OP8 Regulation 14 Requirement Timescale for action 01/02/10 2 OP27OP27 OP12OP12 18 3 OP26OP26 23 4 OP22OP22 23 The care plans must record all the care required to ensure that individual’s needs are consistently met. (Previous timescale of 01 April 2009 not met) The residential forum workings 30/12/09 and copies of staff rotas must be sent to the Commission to evidence how the staffing levels have been determined and are to be implemented. This is to ensure that people’s dependency levels are considered when planning staffing levels and sufficient staffing is provided to meet people’s needs. The carpets in communal areas 01/02/10 must be cleaned or replaced where staining cannot be removed or unpleasant odours controlled. This is to ensure a more pleasant environment for people living in the home. The hoist which was out of 30/12/09 commission at the time of the inspection must be repaired or additional moving and handling aids provided. Written DS0000002849.V378236.R01.S.doc Version 5.3 Hazelmere House Care Home Page 27 5 6 OP34OP34 OP33OP33 25 24 7 OP36OP36 18 conformation of this must be provided to the commission. This is to ensure that there is sufficient moving and handling equipment available to meet people’s needs in a timely manner. A business development plan 30/12/09 must be provided to the Commission. An effective quality assurance 01/02/10 and quality monitoring system must be implemented to ensure that the service is run in the best interests of the people living in the home. (Previous timescale of 01 May 2009 not met) Staff must be provided with 01/02/10 supervision at least six times per year to ensure staff are supported to in their role. (Previous timescale of 01 May 2009 not met) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2 3 4 Refer to Standard OP7 OP7 OP7 OP19 Good Practice Recommendations Records relating to the care provided such as daily diary records should be more detailed to enable effective review of the care plan. People using the service or their representative should have the opportunity to read and agree their care plan. The manager should complete detailed audits of the care plans and provide written instructions for improvement to the care staff. A refurbishment plan should be developed to show how DS0000002849.V378236.R01.S.doc Version 5.3 Page 28 Hazelmere House Care Home the decoration in communal areas is to be improved. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 29 Care Quality Commission Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries.yorkshirehumberside@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 30 Hazelmere House Care Home DS0000002849.V378236.R01.S.doc Version 5.3 Page 31 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!