Care Home: Hazelwood Care Home

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What the care home does well Residents said they found the transition into the home a positive experience and found the staff to be " supportive". Residents said they were "well looked after", and "had positive experiences in the home" as a variety of activities was available to them, which they enjoyed. They spoke positively about the staff team and the management team and were satisfied with the delivery of care, which they said, "is always provided in a respectful and dignified manner". Residents were happy with the environment which they said was homely, and all of those spoken with liked their bedrooms. There are systems in place to enable residents to provide feedback about the home and make suggestions for improvements. Relatives said they are able to visit when they wish, and was "always welcomed into the home by the staff team". They said, "we are always kept informed of the well being of our family member". The staff team are committed to their role and to ensuring that residents receive a good standard of care. They have access to training opportunities to ensure they are skilled and able to fulfil their roles. What has improved since the last inspection? One requirement was made in the last inspection report in relation to the staffing levels in the home. Issues about this were raised during this inspection and therefore this requirement has been repeated. However since the last inspection report the deployment of the staff team has been reviewed and changed to try and ensure sufficient staff are on duty, but the home currently have 3 vacancies which has impacted on the staffing levels in place. What the care home could do better: The information obtained and recorded about each individual would benefit from being in more detail so that person centred care can be delivered and underpinned by written records. This includes information about people`s history and background, and elements of the care plan to be written from the person`s perspective, and how they would like to be supported rather than a general statement such as "assistance of one carer required ". The documentation in place would benefit from being reviewed to include the six strands of diversity, which are: race, gender identity, disability, sexual orientation, age, religion and belief. This will make it inclusive to all people. The staffing levels at the home need to kept under review and information provided to the corporate provider about short staffing. Where possible relief staff should be used to fill vacancies until permanent staff are employed.Residents should be consulted to ensure a staff shortage is not impacting on the delivery of their care. A delegate of the provider should visit the service to ensure that standards are being maintained and complete a report of their findings. CARE HOMES FOR OLDER PEOPLE Hazelwood Care Home Skeavingtons Lane Cotmanhay Ilkeston Derbyshire DE7 8SW Lead Inspector Claire Williams Unannounced Inspection 15th April 2008 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hazelwood Care Home Address Skeavingtons Lane Cotmanhay Ilkeston Derbyshire DE7 8SW 0115 9098100 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) pam.wardle@derbyshire.gov.uk www.derbyshire.gov.uk Derbyshire County Council Manager post vacant Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30) of places Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th May 2007 Brief Description of the Service: Hazelwood is a care home currently registered to provide personal care and accommodation for 30 older people of either gender. The single-storey home is owned by Derbyshire County Council and is situated in the village of Cotmanhay on the outskirts of the town of Ilkeston. The Home comprises of separate wings, each with a lounge and dining area. There is also a larger communal lounge area situated near to the main entrance and the administration offices. All bedrooms are single occupancy. There is separate bath/shower and toilet provision (no bedrooms are equipped with en-suite facilities). The Home has a hairdressing salon. Support services include General Practitioner, district nurse, chiropodist, dentist and optician. The home has a rehabilitation centre, which has been developed using one of the wings of the home. This service is operated independently from the home. The fees for the home range between £102.90 and £392.18 per week. Items not covered by the fees include: toiletries, hairdressing, and transport Hazelwood Care Home DS0000035716.V362481.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 the service is two star. This means the people who use the service experience good quality outcomes The focus of inspections undertaken by the Commission for Social Care Inspection (CSCI) is upon outcomes for people and their views of the service provided. This process considers the home’s capacity to meet regulatory requirements, minimum standards of practice; and focuses on aspects of service provisions that need further development. The inspection visit was unannounced and took place over a period of 6 hours. In order to prepare for this visit we looked at all the information that we have received, or asked for, since the last key inspection on the 23rd May 2007 This included: • The annual quality assurance assessment (AQAA). This is a selfassessment that focuses on how well outcomes are being met for people using the service. • What the service has told us about things that have happened in the service, these are called ‘notifications’ and are a legal requirement. • The previous key inspection report. • We sent out surveys and received 8 staff, 11 from the people that use the service and 3 from relatives. The comments from these have been included in the report. During the site visit case tracking was included as part of the methodology. This involved the sampling of a total of three residents representing a cross section of the care needs of individuals within the home. Discussions were held with those residents as able, together with a number of others about the care and services the home provides. Their care planning and associated care records were also examined and their private and communal facilities inspected. Discussions were also held with staff about the arrangements for their care and also for staffs’ recruitment, induction, deployment, training and supervision. We also spoke with 2 relatives who were visiting the home at the time of this visit. Following discussions it was agreed that the people who live in this service would be referred to as ‘residents’ for the purpose of this report. What the service does well: Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 6 Residents said they found the transition into the home a positive experience and found the staff to be “ supportive”. Residents said they were “well looked after”, and “had positive experiences in the home” as a variety of activities was available to them, which they enjoyed. They spoke positively about the staff team and the management team and were satisfied with the delivery of care, which they said, “is always provided in a respectful and dignified manner”. Residents were happy with the environment which they said was homely, and all of those spoken with liked their bedrooms. There are systems in place to enable residents to provide feedback about the home and make suggestions for improvements. Relatives said they are able to visit when they wish, and was “always welcomed into the home by the staff team”. They said, “we are always kept informed of the well being of our family member”. The staff team are committed to their role and to ensuring that residents receive a good standard of care. They have access to training opportunities to ensure they are skilled and able to fulfil their roles. What has improved since the last inspection? What they could do better: The information obtained and recorded about each individual would benefit from being in more detail so that person centred care can be delivered and underpinned by written records. This includes information about people’s history and background, and elements of the care plan to be written from the person’s perspective, and how they would like to be supported rather than a general statement such as “assistance of one carer required ”. The documentation in place would benefit from being reviewed to include the six strands of diversity, which are: race, gender identity, disability, sexual orientation, age, religion and belief. This will make it inclusive to all people. The staffing levels at the home need to kept under review and information provided to the corporate provider about short staffing. Where possible relief staff should be used to fill vacancies until permanent staff are employed. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 7 Residents should be consulted to ensure a staff shortage is not impacting on the delivery of their care. A delegate of the provider should visit the service to ensure that standards are being maintained and complete a report of their findings. Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 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 Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 1, 2, 3, and 5 (6 not applicable in this Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to the required information and assessment process to ensure this home is right for them. EVIDENCE: In the self-assessment that we received they said they would ensure potential residents are always invited to pre-visit the home: this can be a day visit, usually followed by a three week short term care period prior to permanency. Care managers complete the needs assessment before there assessment takes place. They see this as a two-way assessment: ensuring that they can meet the needs of the potential service user, and they are happy with the service, which is being provided. They said each resident is given a Service user guide complete with Statement of Purpose. Copies of the Service user guide, and Statement of purpose were seen around the building. Feedback provided in the surveys from the residents and their relatives confirmed that they had access to the required information to be able Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 10 to make a choice about the home. These documents however would benefit from being reviewed as they were dated 2006 and therefore residents may not be accessing up to date information about the service. We looked at three peoples file and each file did contain a statement of the terms and conditions of residency. This document provided key information to ensure that residents are aware of their rights and responsibilities, and stated the fees payable. The resident’s files also contained an assessment of their needs, which had been completed by their Care manager. This enables the staff team to gain an insight into what support resident’s need and what their preferences are. Each file did contain specific information about the individual, however information in relation to ethnic origin and marital status was not always completed. Residents and relatives that were spoken to said they had visited the home or stayed for a period of respite in order to make sure this home was the right place for them. Comments received from residents about there admission include: “I was unsure at first so I came to stay for a period of respite, to try it out, and I have been here since as I liked it so decided to stay”. “I settled in straight away, people are very friendly here” The home does not provide intermediate care and there was no residents accommodated at the time of the site visit with diverse cultural or religious needs. It would be beneficial however for all documentation to be reviewed considering the six areas of diversity, and for this information to be filled in upon individual’s admission to the home. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 7, 8, 9, and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents health, personal, and social needs are met in a dignified and respectful way. EVIDENCE: In the self-assessment that we received they said managers and staff have excellent observational skills regarding residents physical well being. Managers always ere on the side of caution and request a GP visit if residents show any signs of ill health. They said care plans/personal service plans are reviewed six monthly or as required and that residents take an active part in the implementation of these. They have a safe system of work for the handling and administation of medication and comply to there Medicines code and policies. Each of the three files that were examined contained a ‘Face’ care plan, which provided staff with information about how to meet each persons support needs. The detail in the care plans varied between each plan, and although there was sufficient detail provided to inform the delivery of care, the Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 12 information was not recorded in a person centred way. For example in one care plan its states (in the personal care section), ‘full assistance by one carer’. The actual type of assistance was not recorded, and what the individual was able to do for himself or herself was also not recorded. However when the staff members was spoken to about this person and how to provide support, they were able to verbalise this in a person centred way. There was information in ones resident file that indicated they required support in relation to managing aspects of their behaviour. However this issue was not mentioned in their care plan, therefore staff did not have access to written direction on how to respond to this need. Although written guidance was not available, discussions with the staff members confirmed that they had received verbal instruction, on how to support this resident. There was some information in the files about individual’s likes, dislikes, preferences and abilities. However this information was not dated so it was difficult to determine if this information reflected the current preferences of the individual. The files contained limited information about resident’s social history and background. This information is beneficial as it enables the staff team to gain more knowledge about the person. Each care plan contained risk assessments and risk management plans to help minimise risk. However one person’s tissue viability assessment had not been completed in accordance with the guidance since Nov 2007, and the action taken in response to a high score on another assessment had not been recorded. Although these records have not been maintained the staff team had monitored the integrity of the skin of these residents so there was no evidence to support it had impacted on the delivery of their care. There were records to support that resident’s healthcare needs were being met. The care plans were regularly reviewed to ensure that they continue to be up to date and reflect resident’s current needs. Daily records were completed to support the well being of each person and to state any significant events that residents had experienced. This enables the staff members on the next shift to be aware of any issues. It was recorded in a resident’s file that they had a fall, but an accident report had not been completed, as required by law. This was rectified when the assistant manager was informed about this. Residents received their medication as prescribed. The discussions held and the medication records that were seen supported this. However it was identified that staff was using a code, which represents ‘other’, but no written explanation was recorded to state why a specific medication had not been administered. It was reported that all staff that administer the medication have completed training in medication as part of the national vocational qualification (NVQ). An NVQ assessor to ensure they are competent in this area has assessed each staff member. Due to a change in the law the storing of controlled drugs must now be in accordance with the legal specifications. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 13 All residents spoken with said that staff support them in “a safe, respectful and dignified manner”. They confirmed that the staff team always spoke to them using their preferred form of address and respectfully. Observations supported that staff worked in a respectful manner and had developed good working relationships with residents. The feedback provided from the surveys also confirmed that both the residents and their relatives were ‘happy’ with the care provided. People told us that there care needs are being met, and although we have identified short falls in the records people told us that these issues have not affected the delivery of their care. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 12, 13, 14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents find that the lifestyle in the home matches their social, cultural, religious, and recreational interests and needs. EVIDENCE: In the self-assessment that we received they said they create a calm and relaxed atmoshere, and promote a warm welcome to all. They said they promote residents own choice and advocacy. They provide some form of activity on a daily basis and have monthly trips out (residents choice). They have residents forum meetings, and have weekly visits from the local church vicar. They encourage and assist residents to attend their place of worship. Residents spoken to and feedback from the surveys demonstrated that they had “enough to do in the home” and were satisfied with the amount of activities available. A member of staff is now employed with the dual role of laundry and activities. Discussions with this staff member confirmed that a variety of activities are now available on a daily basis Monday to Friday between 11am to 12.30pm. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 15 In addition to the in-house activities, trips out are organised on a monthly basis, to various locations. One resident spoke about a recent trip and made the following comment: “We went to Robin Hood tales last week, and it was great fun, there was lots of school children and lots to see and do”. Residents said they looked forward to their forthcoming trip to the theatre, and many residents are looking forward to the completion of the new sensory garden that will be opened in May 2007. The relatives spoken with and feedback from the surveys confirmed there were no restrictions on when they could visit. They said, “The staff always make me feel welcome”. Other comments made included: “The staff and manager always keep me well informed” “the staff are very good and we all have a laugh, which is important ” We joined the residents for their lunchtime meal. The staff team served the meals and the atmosphere was relaxed. The menus in place reflected that choices were available at all mealtimes and this was supported by residents comments. The cook was aware of any dietary requirements and she spoke with residents after the meal in order to get feedback. A cake was made and everyone celebrated a resident’s birthday. Comments made about the food included: “the food here is great” “Its hard not to put weight on as we get lots of food and lots of choices”. “I really enjoy my meals and the food here is good but we get too much, I have put weight on” Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 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 procedures and training that staff have undertaken enable them to encourage and support residents to express their concerns and to safeguarded them from risks. EVIDENCE: In the self-assessment that we received they said there complaints procedure is visible and accessible with clear and precise timescales of how complaints are dealt with. All managers and staff are fully trained in Adult Protection procedures and all residents are supported and encouraged to use the managers open door approach. They said they are proactive regarding freedom of speech and human rights and offer advocay services if needed. Residents and their relatives said they knew how to complain and said they would not hesitate to speak with the staff members or the manager about any concerns. This was supported by the feedback received in the surveys. There was 3 complaints recorded in the file and these had been responded to appropriately and within the required timescales. The Commission for Social Care Inspection have not received any complaints about this service. The home had received many thank you cards complimenting them on their “hard work”, dedication of the staff team, and about the “good care” they had provided to residents. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 17 Procedures were in place in relation to safeguarding vulnerable adults including whistle blowing procedures. Staff members spoken to had a good understanding of what action to take if they witnessed a potential abusive situation. All staff spoken to confirmed they had received refresher training in this area. There have been no notifications since the last inspection. Residents spoken to said they felt safe living in this home. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 19, 20, 22, 23, and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a safe, and comfortable environment, which encourages their independence. EVIDENCE: In the self assessement they said the home is well presented, has no odour, is well decorated, and is tastefully furnished. Care and domestic staff are trained to high standards to maintain high standards of hygiene. Maintenance checks are carried out on a regular basis and the appropriate certificates are obtained. They said they comply with the requirements of Environmental health, Fire officers and Health and Safety legislations. Kitchen staff are trained to maintain a clean and safe environment for them to prepare food. Equipment needed for poor mobility/ dining needs/bathing needs are provided and there is a call bell system for service users in all rooms. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 19 A tour of the building was undertaken upon arrival, and all areas seen were well maintained and decorated to a good standard. Residents spoken with said they were happy with their surroundings and the following comments were made: “I like my bedroom it is lovely and very bright”. “the home is always clean and smells nice, the domestic’s do a good job”. Residents said they have access to various aids and equipment in order to assist them in their mobility and to get around the home. Residents said they were able to personalise their bedrooms and observations supported this. Feedback provided by the surveys supported that residents felt that the building was homely in design and well maintained. Relatives also said that a comfortable and homely environment was provided at all times. As mentioned previously residents are looking forward to the completion of the new sensory garden, and said they intend to make full use of the facilities in the forthcoming months. A wander guard system has been fitted to all external stores in this home, so an alarm rings when the doors are opened. This provides additional security and alerts staff when residents open an external door. However it is also a form of restraint and should therefore be mentioned in the Statement of purpose and a policy should be developed, so that residents are aware of their rights. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 27, 28, 29, and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff in the home are trained, and skilled which ensures residents needs are met. However the inconsistent staffing levels have the potential to affect residents well being. EVIDENCE: In the self-assessment they said they promote motivation, strengths,and confidence building. The staff are trained to high standards and every endeavour is made to provide any further training they may request/need. Staff are trained to NVQ level 2 and above. They listen to staff and respect their opinions and supervision and development plans are implemented. All staff receive induction training, and new staff have a six month probationery period. They treat staff with respect and value them as an asset. Residents and their relatives spoke very positively about the staff team, and comments confirmed that the staff team were available when needed. Relatives said that the staff were “always polite and made me feel welcome” whenever they visited the home. Residents said that they did not have to wait too long to be assisted and that staff members were “very responsive to their needs” when providing support. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 21 Discussions were held with all of the staff members that were on duty and comments were made about the occasions when the home is short staffed. The staffing complement was raised previously in the last inspection report and the outcome for people was rated as poor. In response to this, the staff rotas have been changed to ensure that 3 members of staff are on duty on a morning and evening shift, and some of the residents with high dependency needs have moved on to alternative accommodation. There are currently 3 care vacancies, which are being covered by the existing staff, but interviews were due to take place this week. It was reported that at times it was difficult to cover the shifts and on occasion only one member of staff has been on duty on an afternoon shift supported by a deputy manager. The issue of working alone was also mentioned in the staff surveys and some comments were made that at times the manager on duty does not always assist the staff member during these situations. The feedback provided in the staff and residents surveys also supported that at times the service is sometimes short staffed. A comment made in a resident survey included: “sometimes the staff are very busy doing other things – they cannot be everywhere at once”. Although there are periods of staff shortages, the staff team have attempted to minimise any affects this may have on the residents and staff said “we work as a team, and ensure we meet everyone’s needs, we are just rushed off our feet in the process”. The staff members all made comments about how much they enjoyed their role and were committed to ensuring residents received “a good standard of care”. Observations supported these comments and the motivation and enthusiasm of the staff team. The staff recruitment files are now kept in a central location and not at the home. Information provided in the self-assessment supported that all of the required recruitment checks are undertaken. Discussions with the staff members also supported that all of the checks had been undertaken before they could start employment. This means residents are safeguarded by the recruitment procedures followed. The staff training information is now stored on a computer system, but the deputy manager was unable to access this information at the time of the visit. Some paper records were in place and these did support that staff had undertaken all of the required mandatory training. Staff spoken with also confirmed they have positive training opportunities and regular updates in all of the required areas. Staff have not yet attended Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 22 training in relation to the mental capacity act, which is key training that is required as it concerns how to support individuals to make decisions. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): National Minimum Standards 31, 33, 35, and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed in an open and respectful way and in the best interests of the residents. EVIDENCE: In the self-assessment they said they are a dedicated team who all have the same aspirations for the establishment and service. They are trained and competant to run the establishment in a professional manner. Audits are kept up to date and systems are maintained. They have an open door approach and promote residents rights. The staff are encouraged and supported and they have a transparent and accountable structure Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 24 The acting manager is experienced and has worked in the home for a long period of time. She has commenced processing her application to register with us as the manager for this service. All those spoken with had positive comments to make about the acting manager for example; Residents said ; “she is very good and kind, and approachable, and so are all of the managers” Relatives said: She is easy to talk to and always makes time for you as do all of the managers” Residents said they felt the home is well run and the management team were always on hand for support and advice. Staff spoken with, said they ‘generally felt supported’ by all of the managers, who they described as approachable. The deputy manager confirmed that the management team do monitor the staffing levels and are aware that at times there are staff shortages and they assist the staff were possible. It was reported that a recent quality assurance survey had been completed, and the corporate provider had completed a report of the findings. A copy of this was seen and will be displayed in the home, once the discrepancies identified are rectified. Residents are consulted about aspects of the service through the provision of residents meetings. However the records indicated that one meeting has been facilitated this year and one meeting was held last year. Residents however said they are consulted about things but on an informal basis. Residents who do not wish to hold their own money place it in safekeeping. and the systems in place ensure it is kept safe and there is an audit trail of any transactions. A delegate of the provider has not visited the service to monitor and check on the standards of the service, due to sickness, and therefore no reports or visits have been undertaken since Summer 2007. It was reported that the area manager for this service is however kept informed of any issues. Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 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 3 3 3 X 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X 3 3 X X 3 STAFFING Standard No Score 27 2 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 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 OP7 Regulation 15 (1) Timescale for action In accordance with new guidance 01/08/08 the care plans must be completed in more detail so that they are person centred and reflect how the person would like their support to be provided. They must also include reference to the individual’s ability to make decisions under the requirements of the mental capacity Act. The tissues viability assessments 01/07/08 must be reviewed and completed in accordance with the guidance to ensure they reflect the action taken by staff to monitor the integrity of resident skins. Systems and procedures must be 01/07/08 in place to ensure that an accident report is completed when a resident has a fall or accident. This is required by law and to ensure accidents are monitored and reviewed to minimise any risks to residents The storage for controlled drugs 01/10/08 must comply with the royal pharmaceutical requirements. This is to ensure medication is stored in accordance with the DS0000035716.V362481.R01.S.doc Version 5.2 Page 27 Requirement 2. OP8 12 (1) (a) 3. OP8 17 (1) (a) 4. OP9 13 (2) Hazelwood Care Home 5. OP27 18 (1a) 6. OP30 18 (c) (i) law. The deployment of staff must be monitored and sufficient staff must be on duty to meet resident’s needs. (This issue was raised in the last inspection report) All of the staff must attend mental capacity training to ensure they work in accordance with this new legislation and promote individuals rights to make decisions about their lives. 01/07/08 01/09/08 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. Refer to Standard OP1 Good Practice Recommendations The Statement of purpose and Service user guide should be updated to reflect the changes to the inspection schedule, and to ensure all information is still valid. The wander guard system should also be included in this document. The admission records should be reviewed to incorporate the following areas of diversity: race, gender identity, disability, sexual orientation, age, religion and belief. These areas should be completed for each resident. A reason for not administering medication should be explained in addition to using a code on the medication record. Residents meeting should be facilitated on a more regular basis, to enable them to talk about the running of the home. A policy should be developed about the use of the wander guard system that has been fitted to all external doors. A delegate of the provider should undertake monthly visits to the service in order to monitor the standards in the service and complete a report of the findings. 2. OP2 3. 4. OP9 OP33 5. 6. OP33 OP33 Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Eastern Region Commission for Social Care Inspection Eastern Regional Contact Team CPC1, Capital Park Fulbourn Cambridge, CB21 5XE National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hazelwood Care Home DS0000035716.V362481.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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