Inspection on 07/03/08 for 39 Hawthorne Grove

This inspection was carried out on 7th March 2008.

CSCI found this care home to be providing an Good service.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

39 Hawthorne Grove 31/08/06

39 Hawthorne Grove 10/10/05

39 Hawthorne Grove 18/04/05

39 Hawthorne Grove 22/11/04

39 Hawthorne Grove 27/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Hawthorne Grove (39) 39 Hawthorn Grove Trowbridge Wiltshire BA14 0JF Lead Inspector Alison Duffy Unannounced Inspection 7th March 2008 09:30 Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 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 Hawthorne Grove (39) DS0000036132.V358980.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 Adults 18-65. 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. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorne Grove (39) Address 39 Hawthorn Grove Trowbridge Wiltshire BA14 0JF 01225 767441 01225 767441 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) Voyage Care Services Ltd Miss Adele Lena Caroline Flegg Care Home 3 Category(ies) of Learning disability (3), Physical disability (3), registration, with number Sensory impairment (3) of places Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st August 2006 Brief Description of the Service: 39 Hawthorne Grove is a 3 bedded home for adults with a learning disability and/or a physical disability. The registered provider is Voyage Care Services Limited. Selwood Housing owns the property. The registered manager is Miss Adele Flegg. Miss Flegg is also the registered manager of another care home, within the organisation. 39 Hawthorne Grove is located within a residential area of Trowbridge, near to local amenities. All people who use the service have a single bedroom. One bedroom has an en-suite bathroom. There is a spacious lounge and a separate conservatory. The kitchen has a dining table, where people usually eat their meals. There is a secluded garden to the rear of the property. Staffing levels are maintained at two staff on duty during the waking day. At night, two staff provide sleeping in provision. An on call management system is available at all times. Hawthorne Grove (39) DS0000036132.V358980.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 2 star. This means the people who use this service experience good quality outcomes. This key inspection took place on the 7th March 2008 between the hours of 09.10am and 2:00pm. Miss Flegg was not on duty. The support workers on duty assisted as required. An appointment was made with Miss Flegg on the 7th April 2008, between 11.25am and 12.45pm to give feedback about the inspection. We met with two people who use the service and two staff members. We looked at the medication systems and at care-planning information, training records and recruitment documentation. As part of the inspection process, we sent surveys, to be distributed by the home to people’s relatives, their GPs and other health care professionals. The feedback received, is reported upon within this report. We sent Miss Flegg an Annual Quality Assurance Assessment (AQAA) to complete. This was completed on time. Some information from the AQAA is detailed within this report. All key standards were assessed on this inspection and observation, discussions and viewing of documentation gave evidence whether each standard had been met. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the experiences of people using the service. What the service does well: Care planning is of a good standard and reflects individual need and the support required. Staff give priority to supporting people with social provision and enabling involvement in the community. There is a well-established staff team who are clearly aware of peoples’ needs and their individual methods of communication. Relatives and staff are clear about using the procedures in place to raise any concern. Staff are clear of their responsibilities to report any suspicion or allegation of abuse. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 6 A robust recruitment process is in place, which gives people who use the service, additional protection. National Vocational Training [NVQ] is promoted with all but the newest member of staff, having NVQ level 2. What has improved since the last inspection? What they could do better: 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. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. While there have been no new people to the service, the organisation’s admission policies would be adhered to, to ensure appropriate placements. EVIDENCE: All people who use the service have lived at 39 Hawthorne Grove for many years. It was therefore not possible to look at the admission process in practice. Within the AQAA, Miss Flegg demonstrated a clear assessment process. She said the needs of the individual would be assessed with the support of family members. The person would be offered introductory visits to the service. A service user guide and statement of purpose would be provided . Two people who completed surveys (with support) said they were asked if they wanted to move into the home. They said they had enough information, before moving in. At the last key inspection, the assessment process was judged to be good. There has been no information to conflict with this view. Based on this and the information given in the AQAA, we believe the assessment process would enable appropriate placements. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a good standard of care planning. People are encouraged to make decisions in relation to their ability. Peoples’ welfare is promoted through a well-managed risk assessment process. EVIDENCE: Within the AQAA, Miss Flegg told us that an individual plan, based on the assessment of need would be developed. The plan would be drawn up with the person, their family/friends/advocate and relevant agencies, as appropriate. She said the plan would indicate individualised procedures that maybe necessary. We looked at two care plans and noted both were clear, detailed and well written. The plans were regularly reviewed and updated. There were detailed guidelines in place to demontsrate preferred routines. The support people needed for tasks such as bathing and eating were in place. Important aspects of the person’s life such as family support and activities were identified. Miss Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 10 Flegg told us that staff were further developing the care planning process. A new format was being introduced. The format gave specific sections which enabled the content of the plan to be clearer. Miss Flegg told us that she was aiming to include sufficient detail, to enable a new member of staff to easily follow each plan. Miss Flegg and the staff on duty were clearly aware of peoples’ needs. We observed good interactions and people responded well to staff on duty. Within a survey, relatives said that the home usually gives the agreed or expected support. One relative told us ‘the 24 hours care XX is receiving is second to none. I hope this continues in the house s/he is in. Thanks to the staff who are caring, kind and helpful to XX and to ourselves. S/he is very happy in her home. We are informed about his/her care and anything s/he needs. Please inform the staff we are very happy with the care s/he is receiving.’ Staff told us within their surveys that care standards and paper work, were aspects the home did well. A high number of the staff team have worked with people who use the service, for many years. They told us that they know people well. They are able to recognise and identify people’s well being from general body language and/or mood. People have no verbal speech. We saw one person lead staff to what they wanted. Staff told us another person uses eye contact and gestures to identify their need. Staff told us people are encouraged to make their own decisions. We saw staff ask people what they wanted to do. They also asked people what they wanted for their lunch. Within care plans, there were clear details of people’s individual methods of communication. Within surveys, people told us they could chose what they did each day. When we arrived, one person was having a lie in. Staff told us they liked to get up late. They said they worked to people’s preferred routines. On the second day of the inspection, people were out either at their day service or shopping. We talked to staff about risk taking. They told us, that due to people’s complex needs, ensuring the person’s safety was paramount. They told us that people would be supported to take appropriate risks related to their everyday lives. They gave an example of a person with epilepsy, being suported to swim despite the possibiity of having a seizure. Each person has a number of risk assessments as part of their care plan. These are regularly reviewed. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Social and leisure activities are promoted and organised according to individual need and preference. People are supported to maintain important relationships and have visitors at any time. Meals are based on traditional cooking and the known preferences of people. EVIDENCE: Staff told us that priority is given to social activity provision. They said that they try to go out with people on a regular basis, even if it is just for a walk. The home has its own vehicle to support journeys as required. Staff told us that one person attends a local day service. They said the service is being reduced and would possibly be withdrawn at some stage. This would have an impact of staffing levels, which is being discussed with people concerned. Miss Flegg told us, specific activity programmes are not in place, as people choose what they feel like doing, on the day. Activities, people enjoy are fully Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 12 documented. Staff can therefore, suggest activities from the list, to enable people a more informed choice. Staff told us that people who use the service are supported to maintain important relationships. People are able to receive visitors in their own room or in any of the communal areas. Information within the AQAA told us there are no visiting times. The AQAA confirmed staff ‘support opportunity to welcome visitors in private or in a chosen communal area.’ Within surveys, relatives told us, they are always kept up to date with important issues. They said the home usually supports people to live the life they choose. The preferred routines of people using the service are detailed within care plans. Staff told us that people are supported to be involved in catering and housekeeping tasks. The level of involvement may depend on the person’s ability. We saw people being supported to prepare lunch. Staff engaged well with people. Staff talked to people using the service, rather than between themselves. Staff showed us the current menu. It contained a range of traditional meals such as cottage pie, pasta bake and cheese and potato pie. They told us the menu was devised on a weekly basis and took into account peoples’ individual needs and preferences. People had cauliflower cheese for lunch. People were involved in its preparation. Within surveys, two staff commented about the food budget. As a means to improve the service, they said ‘to have more money for housekeeping’ and ‘higher food budgets.’ We talked to staff about this. They said the budget was tight and did not allow for many treats. They said they needed to purchase washing powder and cleaning materials from the weekly allowance. This left a reduced amount for food. They said higher budgets had been raised in staff meetings. As yet the allowance had not been increased. Miss Flegg said food allowances had been discussed with senior management. However the home was in line with others. Miss Flegg told us, the budget was adequate, yet best value for money was encouraged. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People receive a high level of support with their personal care routines and have good access to health care provision. Medication errors are minimised through clear, well-managed medication systems. EVIDENCE: People, who use the service, receive full assistance from staff in all aspects of daily living. This support is detailed within care planning information. There are detailed guidelines in place regarding morning and evening routines. Aspects such as ensuring privacy and dignity during the provision of personal care are stated. People rely on staff to recognise and act upon any sign of ill health. All people are registered with a local GP and attend appointments as required. One person receives regular support from the District Nurse. This is documented within the person’s care plan. At the last inspection, we recommended that people be weighed more regularly. This has been addressed. Miss Flegg told us that initially people were weighed monthly. However, due to their weight being stable, monitoring has been extended to two monthly periods. Miss Flegg told Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 14 us that frequency would be monitored and changed, if there was a particular need. We looked at the medication systems. A monitored dosage system was used to dispense medication to people. All staff had received medication training. Medication storage was ordered and receipted appropriately. Staff had generally signed the medication administration record when administering medication. One medication and one topical cream were not evidenced. Miss Flegg told us these were ‘when needed’ medications. This was confirmed within the person’s care plan. We advised that this should be recorded on the medication administration record. Medication information sheets were available within the person’s care plan. One plan stated ‘I am supported by staff to take my medication.’ We advised this statement should be given greater clarity. Miss Flegg told us this would be addressed within the new care-planning format. At the last inspection, we recommended that the medication policy be reviewed to include that medication should not be crushed. This has been done. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a clear complaint procedure, which relatives and staff are confident in using. People are assured greater protection from abuse through the home’s adult protection systems. EVIDENCE: There is a complaints procedure devised by the organisation in place. People who use the service generally rely on others to identify any forms of discontentment. Staff told us about the need to recognise body language, as a potential sign of being unhappy. We talked to staff about what they would do if a relative raised a concern. They told us they would try to resolve the situation by ‘discussing the issue and correcting what was wrong.’ They said if this were not possible, they would encourage the person to speak to the manager. Within surveys, two relatives told us that they knew how to make a complaint. Six staff were also confident of what to do if a relative/friend/advocate had concerns about the home. Miss Flegg wrote about how the home ensures the protection of people, within the AQAA. She wrote ‘provide robust procedure for responding to any suspicion, allegation or evidence of any type of abuse. Provide a whistle blowing policy. Provide appropriate training to staff for any necessary physical intervention.’ Staff confirmed this. They told us they all had a responsibility to Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 16 immediately report any suspicion of abuse. They said they would contact Miss Flegg or any other manager within the organisation. Staff told us that adult protection training forms part of the organisation’s training programme. Miss Flegg told us that all staff have a copy of the local adult protection reporting procedures, ‘No Secrets.’ She said there had been no formal complaints or safe guarding alerts since the last inspection. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. While the home is safe and meets peoples’ needs, some redecoration and refurbishment, would provide a more pleasing environment. EVIDENCE: 39 Hawthorn Grove is a detached bungalow within a residential area of Trowbridge. People, who use the service, have a single bedroom, which is furnished in relation to personal preference and individual need. There is a spacious lounge and separate conservatory. There is a dining area in the kitchen. There is a pleasant enclosed garden with seating area. Staff told us that the carpet in the main hallway had recently been replaced. The lounge, kitchen and some people’s bedrooms would benefit from redecoration. Blinds within the conservatory were broken and need replacing. The kitchen has been in place since the home opened. Although in working order, refurbishment would enhance the area. Staff told us they would like to Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 18 see areas of the home redecorated. They felt this would brighten the environment and make it more pleasant for people. Miss Flegg told us that redecoration of the property had been identified, as a need. She said the funding and the allocation of the work were being considered. One person has an en-suite bathroom. Other people use a bathroom in close proximity to their bedroom. The bathroom was in need of some refurbishment. The seals between the bath and tiles were discoloured with mould in some places. The toilet rail was rusty, which presented an infection control hazard. There were wooden storage units, which were showing their age and not pleasing to the eye. Staff told us they felt the bathroom could be made more homely. The laundry facilities were located in a very small room. Staff told us they met the needs of the service. We saw that the home was cleaned to an adequate standard. The conservatory was in need of vacuuming but the staff told us it was their next job. There were no unpleasant odours. Within surveys, one person told us that the home was always fresh and clean. One person said it usually was. Staff told us they had access to disposable protective clothing, as required. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a motivated, long established staff team who are clearly aware of their needs. People are protected through a clear, well-managed recruitment procedure. Training is promoted yet sessions on specific health care conditions of people would enhance staffs’ awareness further. EVIDENCE: During the day, when the three people who use the service are at home, there are two members of staff on duty. When we arrived, one member of staff had gone to do the home’s food shopping. There were two people in the home with one member of staff. Staff told us they were responsible for all housekeeping and catering tasks. They said staffing levels were sufficient to support people with external activities. At night, two members of staff undertake sleeping in provision. Within their surveys, two relatives told us that they felt staff usually had the right skills and experience to look after people properly. One relative said ‘the staff hopefully are now up to capacity.’ Miss Flegg told us that this probably Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 20 referred to when there was a vacancy and one member of staff was on maternity leave. Miss Flegg told us that the home is now fully staffed. We observed interactions between staff and people who use the service. Staff engaged well with people. Interactions were attentive and respectful. Staff appeared motivated within their role and spoke of peoples’ needs in detail. Within surveys, two people who use the service said that staff always treat them well. They said staff listen and act on what they say. Within the AQAA, Miss Flegg wrote ‘staff are appropriately trained and qualfied. The home has a low staff turnover. Over 50 of the staff team have an National Vocational Qualification [NVQ] level 2.’ Miss Flegg confirmed that all staff except the newest member now have NVQ level 2. One staff told us they were planning to do supervision and appraisal training. We looked at the staff training records. They showed us that all staff have completed their mandatory training. This included subjects such as food hygiene, first aid, manual handling, health and safety and adult protection. We advised that subjects related to people’s health care conditions be included in the training plan. This included learning disability and sensory impairment. Within surveys, three staff told that they often received supervision. Three said they sometimes received supervision. Two staff members told us they would like more team meetings and supervision. As a means to improve the service, there were two comments about staffing. These were ‘employ enough staff at times’ and ‘better pay awards would help continuation of staff.’ In relation to what the home does well, staff said ‘up to date and regular training, finding more activities for the service users to try’ and ‘listens to individual needs, as well as staff.’ Miss Flegg told us that documentation, demonstrating the full recruitment process of new members of staff, is held at the organisation’s main office. A checklist of the recruitment process was held on the person’s file. This showed two written references and a Criminal Records Disclosure, were received before the member of staff commenced employment. Within their surveys, all six staff said checks, to assess their suitability of working with vulnerable people, were carried out before they started work. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People benefit from a person centred manager, who has clear expectations of the standard of service to be provided. Systems are in place to ensure the quality and ongoing development of the service. Peoples’ wellbeing is promoted through clear health and safety systems. EVIDENCE: Miss Flegg is the registered manager of another service within Trowbridge. Staff told us she splits her time equally between the two services, but can be contacted at any time. Miss Flegg is a registered nurse and has the Registered Managers Award. Miss Flegg told us she keeps her PIN number up to date with the required amount of training. Miss Flegg showed us surveys the organisation had sent to people, their families and staff, as part of the home’s quality assurance system. Miss Flegg Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 22 told us this is done on an annual basis. The feedback is taken into account within the annual service review. We advised that the feedback be coordinated within a summary. This would ensure the findings were more easily identified. Senior managers visit the home on a monthly basis. They forward their report to us. The organisation has a range of health and safety policies. Individual and environmental risk assessments have been developed. The fire log book demonstrated satisfactory testing of the fire alarm systems. All staff are up to date with their mandatory training such as first aid, food hygiene and manual handling. All staff have received recent fire instruction. Regular vehicle checks are in place. Staff told us they take the fridge and freezer temperatures daily. There is a record of the temperature of food, served to people. The temperature of the water is also taken when people are being supported to bathe. Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Hawthorne Grove (39) DS0000036132.V358980.R01.S.doc Version 5.2 Page 24 No Are there any outstanding requirements from the last inspection? 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 YA24 Regulation 23(2)(b) Requirement The registered person must ensure that attention is given to the seals in the bathroom, the rusty toilet rail and the broken blinds in the conservatory. Timescale for action 30/05/08 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 2 3 4 5 Refer to Standard YA17 YA20 YA24 YA24 YA35 Good Practice Recommendations The registered person should ensure consideration is given to increasing the food allowance budget. The registered person should ensure that the identified medication and topical cream be recorded on the medication administration record, as ‘when required.’ The registered person should ensure that consideration is given to the redecoration of certain areas of the home. The registered person should ensure that consideration is given to refurbishing the kitchen and making the bathroom more homely. The registered person should ensure that staff training relating to individual health care needs such as learning disability and sensory impairment form part of the home’s training plan. DS0000036132.V358980.R01.S.doc Version 5.2 Page 25 Hawthorne Grove (39) 6 YA39 The registered person should ensure that the feedback gained as part of the home’s quality assurance system is detailed within a summary, for clearer identification. 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