Inspection on 15/10/07 for Hawkesgarth Lodge Nursing & Residential Home

This inspection was carried out on 15th October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hawkesgarth Lodge Nursing &... 09/09/08

Hawkesgarth Lodge Nursing &... 10/03/08

Hawkesgarth Lodge Nursing &... 26/04/07

Hawkesgarth Lodge Nursing &... 18/08/06

Hawkesgarth Lodge Nursing &... 04/01/06

Hawkesgarth Lodge Nursing &... 13/07/05

Hawkesgarth Lodge Nursing &... 05/10/04

Hawkesgarth Lodge Nursing &... 29/04/04

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

CARE HOMES FOR OLDER PEOPLE Hawkesgarth Lodge Nursing & Residential Home Station Road Hawsker Whitby North Yorkshire YO22 4LB Lead Inspector Jo Bell Unannounced Inspection 15th October 2007 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 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.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. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawkesgarth Lodge Nursing & Residential Home Address Station Road Hawsker Whitby North Yorkshire YO22 4LB 01947 605628 01947 605772 hawksgarth@zoom.co.uk www.europeancare.net European Care (UK) Limited 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) vacant post Care Home 40 Category(ies) of Dementia (1), Dementia - over 65 years of age registration, with number (40), Mental Disorder, excluding learning of places disability or dementia - over 65 years of age (40) Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include 40 (DE(E)) and up to 40 (MD(E)) up to a maximum of 40 service users. 60 years plus The category DE refers to the specific service user named in the application of 2nd December 2005 only. 26th April 2007 Date of last inspection Brief Description of the Service: Hawkesgarth Lodge provides nursing care and accommodation for up to 40 service users who have mental health needs and/or a dementia type condition. The home, set in its own grounds, consists of a two storey older building and a more recently built single story unit. The premises are located in the village of Hawsker approximately 3 miles south of Whitby and can be reached by a limited bus service or private transport. The service provides 32 single and 4 shared bedrooms. 10 of the single rooms have en suite facilities. The service is divided into three units. There is a passenger lift within the older part of the building where the accommodation is situated over 2 floors. The rest of the building is single storey. Each ‘unit’ has separate sitting and dining areas. Care staff are usually delegated to work in specific units. Qualified nurses work across all units. The property has an enclosed garden area and ample car parking for visitors and staff. Current fees are £460.00 to £662.00 a week. Additional charges are made for hairdressing, chiropody, toiletries, papers, magazines and dry cleaning. Information about the services provided are made available in the home’s Statement of Purpose, Service Users Guide and through published inspection reports available from the home. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key inspection of the service took place on Monday 15th October 2007. Prior to the visit an annual quality assurance assessment was completed and surveys were sent out to people using the service, their relatives and health care professionals. Two service user surveys, one relative and two healthcare professional surveys were returned. The visit lasted for seven hours, the manager was not available, though one of the nurses was able to assist with the visit when necessary. Three monitoring visits have also taken place since the last key inspection, May 31st, July 5th and August 16th 2007. These were to assess the progress of requirements made regarding staffing issues and support from the organisation. Information was inspected during the day which included :Three Care plans (including the initial assessment) Three Medication charts Risk assessments A selection of Health and safety documentation (which included fire safety) Three Staff training records and recruitment files Discussions took place regarding how people’s money is looked after, how allegations of abuse and complaints are dealt, staffing issues and activities. Aspects of the environment were inspected and the lunchtime meal was observed. Three people using the service, one relative, two nurses, two carers, the maintenance person, the catering assistant and the administrator were all spoken with. At the end of the visit feedback was given to the nurse in charge, and this was followed up with a discussion with European Care. What the service does well: What has improved since the last inspection? Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 6 There has been an increase in the number of bathing facilities, this gives people a wider choice regarding how often they have a bath or shower. The main lounge/dining area has had a new floor covering, and areas of the corridors have also had new floor covering introduced. This has improved the standard of the environments décor for people. 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. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 7 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 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 8 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): 3 (Standard 6 is not applicable) People who use the service experience adequate quality outcomes in this area. Whilst individual needs are assessed, this does not means that needs will be, or can be met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Three assessments showed that information is obtained prior to a person being admitted to the home, whilst this covers health and personal care needs there is little evidence that this then transfers to care needs being met. The care manager carried out an assessment which was available and very detailed. However staff spoken with were unclear about peoples individual needs or what the assessment process consisted of. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 9 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): 7,8,9 & 10 People who use the service experience poor quality outcomes in this area. Health and personal care needs are consistently not met. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: People do not have their care needs met, this was evident when observing people in the lounge and dining areas. Three people in one area looked unkempt, with dirty nails, un-brushed hair and men were unshaven. One lady needed her trousers changing due to staining on them, one man said “ I really need a shave”, another person has blood on their face and no explanation was given for this. Care given was poor and staff did not know how to improve this. Staff did not communicate effectively with people and privacy and dignity was not maintained. People have individual care plans in place. Three were checked at it was evident that these needed to be reviewed and re-evaluated. Some information was available which demonstrated specific plans had been developed, though this was not consistent throughout. Some risk assessments regarding nutrition and the prevention of pressure sores were in place though Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 10 there was a lack of action taken when an issue had been identified. For example one person had lost 5kgs in 2 months, the registered nurse confirmed she did not have time to write a care plan and re-evaluate this person’s care. This is having a negative effect of the well-being of certain individuals. Staff are attending a continence course which helps staff identify the needs people have regarding continence. The care delivered during the night was discussed and one care plan identified that the night staff do not routinely record night time activities, for example one person who had been extremely unwell and needed the doctor calling when day staff arrived to do their shift only had a record in the notes for ten minutes before the night shift ended. It is difficult to identify what care had taken place during the night or when the person’s condition deteriorated, or if appropriate action had been taken. On one occasion a person wandered into the dining area in a wet nightgown, with no slippers on and with a wet continence pad on display. This was clearly distressing for the person. Staff should have the knowledge and skills to be able to negotiate with this person to ensure she has autonomy and choice regarding the clothes she wears and the time when she gets up, and the need to have her personal care met. Whilst staff spoke to this person in the dining room and helped her to go back to her room, the person’s dignity had already been unmet. The home have a suitable medication system in place. Though it is not currently audited and therefore it is difficult to identify where errors have occurred. An error with a controlled drug had previously occurred, and the light outside the medication room to alert people that this cupboard is being used is broken. Three medication charts show that generally medication is administered correctly. Currently the temperature of the fridge is not recorded which could mean that medication is stored at the incorrect temperature which may be harmful. The bin used for sharps does not have a lid on which puts staff at risk of a needle stick injury. Staff do not receive specific medication training or updates which would enhance their practice. The medication room is small and there is no sink for staff to wash their hands in, this would be beneficial to prevent any cross contamination. Whilst outcomes for people are currently positive regarding medication people are being put at risk because of the potential of harm. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 11 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): 12,13,14 & 15 People who use the service experience poor quality outcomes in this area. Some activities are available but autonomy and choice is not consistently encouraged. The dining experience for people needs considerably improving. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home have an activities organiser who plans a weekly programme of activities. She does not work Mondays and therefore was not available at this inspection. Information from the annual quality assurance assessment stated that “families are encouraged to visit regularly and the home maintains links with the local community”. There is a Library service available and a regular entertainer visits the home. Autonomy and choice is not routinely offered, there was no evidence to suggest that people could be flexible regarding their daily routines. For example the time people could get up or go to bed, or whether they could sit outside in the garden or go out with a member of staff for some fresh air. Religious needs were discussed in individual care plans but staff had no understanding of how these needs were being met on a daily basis. One visitor confirmed that they could visit when they wanted to, and Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 12 the visitors book confirmed this. The lunchtime meal was observed. The large dining/lounge area was mainly used, though some people ate in their room, it was unclear as to whether this was their choice. The dining table and chairs were suitable and the atmosphere was calm. However it was evident that the whole dining experience could be improved on. The portion sizes were extremely large this meant that it could take up to ninety minutes for staff to assist one person, by the end of this time the food was cold and unappetising. There are sufficient staff at lunchtime, when the home is fully staffed but because of the system for assisting people staff were constantly getting up and down to help other people. Apart from one carer who assisted someone in a dignified manner, staff including care staff and nursing staff communicated ineffectively with people, for example some comments which were made by staff whilst assisting people included “ a bit loose today” this referred to a named person and their bowel activity, “don’t be spitting everywhere”, this comment was made to a person having their lunch. Many comments were made at the table regarding the care of different people. One member of staff said in a patronising tone “good girl” when an elderly person had taken a mouthful of food. Staff were not respectful to people i.e “I will leave that drink there”, and then saying to the staff “she will probably spill it”. The majority of the food served was left, but this was not documented anywhere and no action was taken to identify why this was the case. The kitchen staff discussed the menu and the choice people have, hot food is available at lunchtime and tea time and drinks are offered during the morning and afternoon. During the morning a trolley of ready made coffee with milk and tea with milk was offered. No biscuits or fruit is available and if people choose to have black coffee this then becomes a problem for staff as they then have to go and make this specially. Staff do not understand that people must be offered a choice of hot and cold drinks which are not to fit in with the routine of the staff. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 13 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): 16 & 18 People who use the service experience poor quality outcomes in this area. People are not confident that their complaints will be actioned effectively, and they are not protected from harm. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home have a complaints procedure in place, though staff were not aware of the details of this. Surveys generally confirmed that people were aware of the complaints procedure and one relative said she would speak to a member of staff if she had any concerns. Concerns have been raised regarding some care practices in the home. The organisation has investigated some of these concerns and another was referred to the vulnerable adults team. Staff in the home do not feel able to express their concerns regarding other staff members relating to poor care practices. This was evident at lunchtime, poor practice was identified but no action was taken because people were concerned what the repercussions would be if they were seen as the ‘whistle blower’. The culture of the home is not open and many practices are institutionalised which is detrimental to people. Whilst staff are aware of different types of abuse they are not able to voice their concerns effectively, this leads to people not being treated appropriately and people are then not protected from harm. This needs to be resolved as a matter of urgency. Following later discussions with European Care it was evident that there is an Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 14 adult protection procedure in place and a whistle blowing policy, though this was not seen at the inspection. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 15 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): 19 & 26 People who use the service experience poor quality outcomes in this area. People live in a home which smells unpleasant and is not adequately maintained. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home is located in the North York Moors in a pleasant setting. There are enough communal areas including a large lounge and dining area. The home has undergone some improvements regarding additional bathing facilities and new floor coverings in the lounge and corridor areas, this has enhanced the area for people. The home does have an extremely unpleasant smell of urine and faeces in many areas. There is a current infection control issue (viral) and there has been a previous diarrhoea and vomiting outbreak three months ago. Staff do wear some protective clothing in the form of gloves and aprons, but many areas are left unclean because the domestic staff finish Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 16 work at 2pm. Staff are not able to wash their hands properly due to the type of taps fitted in many rooms and staff confirmed they have not received infection control training. In one area a floor had been mopped and in the corridor water was evident, no sign had been left in the corridor to alert people to the wet floor. One person was walking down the corridor and was unaware of the potential risk this posed. The laundry area has sufficient washing machines and tumble driers though concern was expressed regarding the length of time one tumble drier takes to dry clothes, because of this care staff often have to deal with the washing when the domestic staff have finished work. The home have two sluice areas though currently one is out of order. Staff have to walk a long way to empty commode pans, this poses a risk of cross contamination. The issue regarding the smoking area has been addressed, people using the service who smoke have to go outside if they choose to smoke. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 17 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): 27,28,29 & 30 People who use the service experience poor quality outcomes in this area. People are not cared for by staff who are competent or in sufficient numbers to safely meet their needs. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Those staff spoken to in the home and observed during the visit are not suitably trained to meet peoples needs. Surveys confirmed that staff do not have the right skills and experience to always meet peoples needs. This was evident through observations during the day. At the visit there were two registered nurses and six care staff on duty and whilst this seems adequate due to their poor communication and lack of understanding of the needs of people with mental health problems needs were not being met and people were treated in an undignified manner on numerous occasions. Previously staff had been working sixteen and eighteen hour shifts, this was raised at the last visit and the organisation agreed to stop this happening again. However on the day of the inspection one person had just finished working a nineteen hour shift which was from the previous afternoon and throughout the night. This is the only occasion when this has happened. This is not acceptable because this puts people at risk when staff are tired and having to work long hours. The duty rota was inspected and over the weekend three care staff are expected and agency staff will have to be used, though none had been organised. Following further discussion it was evident that agency staff are organised only Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 18 a few days before being needed. Staff morale was extremely low, staff feel they are poorly paid, they do not receive enough training and they are expected to regularly work thirteen hours shifts. None of this is conducive to improving care practices in the home and enhancing the outcome for people living there. This is further compounded by the fact that care staff have to carry out domestic duties from 2pm everyday and during the night as there is no domestic staff available. This then takes care staff away from caring for the people using the service. Some staff have completed an NVQ level 2 in care though there does not appear to be an expected level of care for staff to meet. A further six staff are hoping to complete this training, this was confirmed with the manager following the visit. Induction training is offered though no records were available to confirm this takes place. One person spoken to said ‘I had a days induction’ but this was not detailed, and did not prepare me for this client group’. Action needs to be taken to ensure people have adequate induction and training so needs can be met. The home does recruit people effectively. Three files confirm that written references are obtained, a police and protection of vulnerable adults check is carried out prior to staff starting work and an application of health declaration is completed. Whilst this helps protect people from harm, the calibre of staff employed do not have the required skills, knowledge or understanding to care for this client group. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 19 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): 31,33,35 & 38 People who use the service experience poor quality outcomes in this area. The home is not run in the best interests of people living in the home. This has a detrimental effect of the well-being of people using the service. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The home is currently run for the benefit of the staff and not the people living there. Discussions with the manager following the visit confirmed this. At the site visit the manager was away for three weeks, there was no deputy in place and there was a lack of support from the organisation for the staff who were looking after people in the home. The person is charge was unaware of any quality assurance system in place and staff were not observed asking people if they were happy, or comfortable in the lounge or other communal areas. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 20 Staff need further mandatory training including fire safety, moving and handling, infection control and first aid. Whilst some records confirmed a limited amount of training had taken place it was evident from the staff that suitable training for this client group is not regularly offered. People spoken with had a limited understanding regarding how their views and opinions are sought relating to the type of service provided (due to their condition). One relative confirmed she would speak to a member of staff. It is unclear as to whether residents meetings take place or if audits of care plans, medication or health and safety systems takes place. The administrator confirmed that people are able to keep a certain amount of money in the home for hairdressing, chiropody, toiletries etc. Three records confirmed that this system is effective. Health and safety was discussed in the annual quality assurance assessment and with the maintenance person. Contracts are in place for electrical equipment, hoists, the call bell system and machines in the laundry. Water temperatures are tested regularly and generally these were adequate. However, the taps that most people have are the ‘push down’ type. This makes it extremely difficult to fill a sink full of water as it normally stays on for only a few seconds. Staff are unclear as to what action to take in the event of a fire, fire drills do not take place and some staff spoken to said they have never been shown what to do. This needs to be addressed. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 21 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 2 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 2 10 1 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 1 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 1 17 x 18 1 1 x x x x x x 1 STAFFING Standard No Score 27 1 28 1 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 x 1 x 3 x x 1 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 22 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 Requirement Timescale for action 15/11/07 2. OP10 12(4(a)) Care plans must be regularly reviewed and evaluated to reflect any changes. This will ensure needs are continually met. People must be treated in a 01/11/07 respectful and dignified manner by staff, at all times. People must be assisted at mealtimes in a dignified manner with staff communicating effectively with people. The registered provider must ensure that the home is kept clean and free from offensive odours at all times. Previous timescale not met (24/08/06 & 18/08/07) 15/11/07 3. OP15 16(2(i)) 4. OP26 12(1)(a) and 16 (2)(j&k) 15/11/07 5. OP27 18 Staffing numbers must be urgently reviewed and appropriate cover put in place to ensure that there are sufficient staff available at all times and DS0000028005.V349933.R01.S.doc 15/11/07 Hawkesgarth Lodge Nursing & Residential Home Version 5.2 Page 23 staff are not expected to work 16/18 hour shifts. Previous timescale not met (21/08/07) 6. OP30 18(1)(a, c) Staff must receive training that is specific to the needs of this service user group. This includes: Person centred care Communication Dietary needs of people with a dementia or mental health problem The training must be properly evaluated and staff’s understanding monitored. Requirement made previously only partly met (30/06/07). 15/12/07 7. OP33 24 The quality assurance monitoring 15/11/07 undertaken by the service must show how its outcomes are actioned. Previous timescale of 30/11/06 not met. 8. OP38 23 Staff must receive fire training to 15/12/07 ensure they know what action to take in the event of a fire. This will help protect people. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations DS0000028005.V349933.R01.S.doc Version 5.2 Page 24 Hawkesgarth Lodge Nursing & Residential Home 1. OP12 The programme of activities must be reviewed to meet individual and collective needs of people. The current style of taps needs to be reviewed as they are not suitable for people using them, and staff are not able to wash their hands effectively. 2. OP26 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ 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 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V349933.R01.S.doc Version 5.2 Page 26 - 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!