Inspection on 18/08/06 for Hawkesgarth Lodge Nursing & Residential Home

This inspection was carried out on 18th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 &... 15/10/07

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

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 Mavis Pickard Key Unannounced Inspection 18 & 24th August 2006 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.V308376.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.V308376.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 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) European Care (UK) Limited Mr Steven William Sullivan 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.V308376.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. 4th January 2006 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 story 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 story. Each ‘unit’ has separate sitting and dining areas. It is usual that the three areas are staffed independently in respect to care workers. Qualified nurses work across all units. The property has an enclosed garden area and ample car parking for visitors and staff. Information received from the home on 7/6/06 advises that current fees are £442.00 to £614.00 a week. Additional charges are made for hairdressing, chiropody, toiletries, papers and magazines. 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.V308376.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The manager has recently left his employment. A deputy manager from another service owned by organisation European Care Ltd, is managing the home. The outcomes for residents were evidenced from speaking with relatives or visitors to the home before or during the site visit and by observing and speaking with people who live at the home during the visit and by examining the care plans of 4 residents Further information about the service was obtained speaking with staff who work at the home and with other people such as care managers and others who have an interest in the welfare of people accommodated. Accumulated evidence was also provided by past inspection reports and other details about the service stored within the Commission for Social Care Inspection [CSCI] records. It was found that although records show that sufficient staff are rostered for duty. The service does not always have sufficient care staff working in the home and sometimes struggles to give people the individual care that they have been assessed as needing. What the service does well: What has improved since the last inspection? Some bedrooms have been re-furbished and re-decorated. Some corridors have been painted. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 6 A tear in the floor covering in a dining room has been fixed and plants have been bought and placed in the entrance to the home. Bed rails are checked regularly to make sure they are properly fitted and safe for residents. People have a choice of food at each meal and the cook has a list of residents likes, dislikes. Some of the requirements of the previous report have been met. The organisation has said that improvement to the premises required by previous report will be done. However they have not given any times for completion. 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. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.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.V308376.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 3, 4 & 5. [6 is not applicable] Quality in this outcome area is adequate. This judgement has been made using available evidence about the service including a site visit. People’s needs are assessed prior to admission and care management assessments are maintained. However there is little evidence that residents or their relatives are involved in the planning of care. The service does not provide intermediate care. EVIDENCE: The service enables prospective residents and their representatives to visit and check out the provision offered prior to admission. However a relative spoken with said, “It’s Hobson’s Choice” this is the only service of its kind in the area. A second relative said that they were satisfied with the process of admission and “the care is good, but it’s not the home I would have chosen had there been a real choice”. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 9 The service undertakes a pre-admission assessment on prospective resident’s that examines their physical and cognitive needs and produces a plan of care. However there is little evidence that emotional or spiritual needs are considered. There is no evidence that families and or representatives play a pivotal role during the assessment and admission of their relative. Staff spoken to do not all have a real understanding of individuals in their care. None of the case files examined included details of resident’s past interests. However from speaking with staff at all levels it is clear that they have the necessary skills and abilities to care for people accommodated. The service has a statement of purpose, which sets out the aims and objectives of the home, and includes a service user guide. This provides basic information about the service. The guide is made available to residents or their representatives before admission. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is adequate. This judgement has been made using available evidence about the service including a site visit. Staff in general are dedicated to providing a reasonable service. However it is clear that because regularly the numbers of staff are depleted, sometimes drastically, they struggle to meet more than basic needs. EVIDENCE: All residents have a detailed well constructed care plan that sets out the care to be provided. Regular recorded reviews are undertaken and action taken where changes are identified. There is evidence from relatives and staff that resident’s representatives are consulted about major issues. However there is no evidence that residents or their representatives are involved at all levels of planning. Care plans are easy to read and they cover all areas of the individual’s physical and mental health needs and personal care. Areas of risk are clearly identified and it is noted where staff support residents to take reasonable risk. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 11 In the main staff regard the care plan as a working tool. However some care staff said that it was several weeks into their employment when they were told that they could and should read care plans. Some staff spoken with did not know much about the past of the residents or how and why they have the need to be accommodated for specialist care. However all residents have a key worker who say it is their aim to provide a ‘key person’ for the resident and their relative. Shortages of staff at key times results in the quality of care being compromised. Staff say that sometimes they are able only to provide basic care and safety. At these times emotional support and specialist care strategies cannot be delivered effectively. Continence management is compromised. Visitors spoken with say that it’s their opinion that the care provided by staff “is very good” and that “the girls go out of their way to really care for residents in a kind way”. The home provides some aids and equipment so that residents can lead a full and able life. However staff said that the equipment is limited, that there are not sufficient bathing facilities, not sufficient appropriate hoists or wheelchairs. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 12 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence about the service including a site visit. Some areas of this outcome are good and residents are supported to lead active and interesting lives. However not all people can exercise choice and control over their lives. EVIDENCE: The service employs an activities organiser who works every weekday. It was clear from observation and speaking with residents, staff and visitors that people are encouraged and supported to be active. Individual and group activities take place. Staff said that residents who are able to are supported to go to shops locally and in Whitby. People are taken out for short trips to the seaside and local beauty spots. The home has open visiting arrangements and residents are enabled to see their visitors in their private rooms if they wish or if they prefer they can use community areas of the home to talk to visitors. During this site visit visitors were seen in the home and to be taking their relatives out. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 13 Residents are able to have personal possessions in their room. The food in the home is of good quality, well presented and meets the dietary needs of residents. It was noted however that all meals are brought to the dining room at one time and kept in an electrically heated ‘hot cupboard’. However the ‘hot cupboard’ was not plugged in. Staff said “it keeps things warm anyway” and that if it were plugged in it would pose a burning risk to residents. Some residents may have to wait to be assisted to eat. It is not clear that people always receive hot food at the appropriate temperature. Staff are trained to help those residents who need help when eating and were noted to be sensitive in their approach. Residents are able to choose to eat in their own room if they wish. Regular drinks and snacks are available. Care and nursing staff understand the need to provide regular drinks. Concerns were raised by staff that drinks are sometimes “whipped away” not giving residents time to finish. Staff said that its common practice that night staff get a number of residents up from 6am onwards, it is understood that there is pressure on night staff to ‘have people up before day staff arrive’. They say its also common practice that should a resident be incontinent late in the afternoon they will be changed into bed clothing rather than clean day clothing. This type of institutional practice is not acceptable and compromises resident’s dignity and choice. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 14 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made using available evidence about the service including a site visit. The service deals effectively with complaints. Staff understands how to keep people safe. However not all staff has received POVA training. EVIDENCE: The service has a complaints procedure that meets the national minimum standards and regulations. The complaints procedure is available within the home. Relatives and others understand how to make a complaint. The policies and procedures regarding protection of residents are satisfactory and are reviewed and updated in line with regulations and external guidance. All staff spoken with knew their responsibilities with reference to the protection of people however not all had received POVA training. Relatives and others associated with the home including care managers and GP’s state that they are satisfied with the service provision, and feel that residents are safe and supported. Residents are supported to live as independently as possible. However there are concerns regarding choice and institutional practice. The home is aware of the need to facilitate advocacy services and there is a note of such services in some resident’s case files. However the acting Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 15 manager and nursing staff spoken with do not know of anyone using such services even though there are people living in the home who have who have no independent representation. Recruitment processes safeguard people living at the home. The home has a whistle blowing policy and staff understand its how to use it. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All Quality in this outcome area is poor. This judgement has been made using available evidence about the service including a site visit. Overall the home presented as not being clean and tidy and of being generally neglected. The environment does not always meet residents’ needs. EVIDENCE: The service admits people who smoke, however no appropriate provision is made to accommodate the people concerned. Residents who smoke sit in a general thoroughfare near the main entrance where all other residents, staff and visitors pass through or congregate. Although an ashtray is provided it often is missing and people throw their cigarette ends out of the patio door. It is noted that an accumulation of these items are on the external pathway to the garden. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 17 The carpet near this ‘smoking area’ shows signs of having being frequently burned. There is no evidence of an on-going maintenance programme being in place. Staff spoken to during this visit said that the organisation ‘pays lip service’ to improvement and nothing more, also that “ its always when the extensions built” that the home is to improve, but that’s “ pie in the sky”, and plans never go any further. Refurbishment has taken place in some bedrooms and some corridors have been painted. However staff and visitors spoken with about this said “ its tinkering ‘round the edges” and “ its always been like that”. There is sufficient communal space but this is sometimes used for other purposes, for example, a staff training room. The acting manager confirmed that this was the case with a general staff meeting having taken place in the residents lounge on 23/8/06. There are sufficient toilets but insufficient bathrooms/shower rooms provided. Bathrooms and shower rooms are used for storage and/or drying rooms i.e. chair cushions and wheelchairs. In the main, bathrooms and shower rooms do not provide pleasant, domestic areas where residents would find bathing and showering a relaxing experience. Rather they are institutional in their décor and presentation. Equipment provided for resident’s is said by staff to be limited to one generalpurpose hoist and three 3 wheelchairs for general use. Staff say that’s not sufficient. The wheel chairs were observed being used without padded seating or backrests and at times without footrests. Throughout the home there are fixtures and fittings that need repair or replacement, in the older part of the home, radiators covers need re-painting, repairing or replacing. The furniture in some bedrooms and communal rooms especially in the older part of the premises are dated and in a poor condition. Some of the window frames in this part of the home are also in a poor condition. The bed linen provided to residents presents as ‘old’ and/or of a poor quality and in a poor condition. All the sheets and pillowcases looked as though they had been washed frequently, they had lost their colour and were in the main ‘grey’. The external gardens and pathways are overgrown and neglected. The garden furniture is dirty. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 18 Disused ‘Baffle handles’ can be found throughout the home on resident’s bedroom doors. These need to be removed and the doors made good. There are some toilet doors that don’t close effectively. Policies and procedures for the control of infection must include guidance that where clinical waste is deposited there needs to be suitable disposal bins. Not all areas where continence products are left for disposal have such bins. The home has a nurse alarm call system however in some bedrooms the reset device is missing. Staff have to re-set using a ‘spent’ match. Staff spoken to about this issue said that this system has been “in use for years” The fire exit near to room 37 a ramped area, is overgrown with vegetation and would be hazardous to use. The acting manager was asked to have this cleared immediately. Although there are notices throughout the building stating that doors should not be held open by unauthorised means, many were. Bedroom doors were wedged open with clothing and a communal door in the older part of the home was held open with a hook and eye device. This was removed immediately. The home in general was not clean and unpleasant odours were detected. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): All Quality in this outcome area is poor. This judgement has been made using available evidence about the service including a site visit. Albeit the service’s recruitment policies and practice safeguards residents and staff who are employed are competent to perform their role. The home does not have sufficient staff on duty at all times to meet the assessed needs of people accommodated. EVIDENCE: The staff rota’s provided to the Commission by the pre-inspection information evidenced that sufficient care staff are expected to be on duty at all times. Staff spoken with are clear regarding their role and what is expected of them. Representatives and some residents say that staff know what they are meant to do, and that they are generally able. The service has a recruitment procedure that is adequate and generally meets the Regulations and the National Minimum Standards. During this visit agency staff were being used. Visitors and staff spoken with said that there are times especially, but not exclusively at weekends when care staff do not present for duty. People in charge at these times spend a long time ringing round ‘off duty’ staff trying to fill the gaps, usually to no avail. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 20 The outcome at such times is poor. Many people accommodated have continence needs. Care plans show that continence management programmes are necessary. The programmes in place cannot be managed when staffing levels are low. The service is divided into 3 units, when staff shortages occur staff and visitors say that people are ‘kept’ together in the ‘middle’ ‘the middle’ is an area in and around the main sitting and dining area. This happens staff say to ensure that people are kept physically safe and where they can be observed by the limited number of staff available. Staffing levels in respect to nursing staff shows that the service has achieved some stability. The administrator of the home said that nurses are a stable group but that is not the picture with care staff. There are some longstanding care staff but there has been a lot of movement in recent times. On weekdays there is a minimum of 2 nurses who works across the 3 units of the home. Additionally there is the manager/acting manager who is also a qualified nurse, the activities organiser and the administrator who together provided adequate staff cover. However at weekends there is usually 1 nurse on duty who works across the 3 units. The manager/acting manager, activities organiser and administrator do not usually work at weekends. This overall lowering of day staffing levels result’s in poor outcomes for residents. Although the organisation indicates in documentation examined by the Commission that it is committed to a robust training programme. Evidence from training records examined and from speaking with staff during this visit is that the training provided is limited. Not all care staff has received moving and handling, first aid or health and safety training. Not all staff generally had received POVA training. Not all care staff has achieved the National Vocation Qualification [NVQ] at a minimum of level 2, although some people are now beginning this course. Staff say that they have not up until very recently been routinely encouraged or supported in the pursuing of external qualifications such as NVQs. Staff said that they were concerned about lack of appropriate induction and training provided to them, about low staffing numbers and about some institutional practice in the home. Overall staff say that there is low staff morale within the service. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 21 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38 Quality in this outcome area is adequate. This judgement has been made using available evidence about the service including a site visit. The day-to-day management is currently appropriate. There is a procedure for staff supervision however it has not recently been followed routinely. There are some health and safety issues identified and evidence of institutional practice. EVIDENCE: The service does not presently have a registered manager. However the deputy manager of another home in the organisation is managing it presently. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 22 It is not clear that residents benefit from an open positive atmosphere. Staff spoken with said they have concerns that some aspects of provision are institutional. Visitors say that the home is neglected by the organisation in a way that they feel is unique to Hawksgarth Lodge. One relative said “ its been left behind”. This service overall presents as having complex needs. Staff say morale is very low which has a knock on effect for residents and their families. There are no concerns noted now or previously concerning resident’s finances. Quality assurance monitoring although undertaken is not evidenced as being used for standard raising and is not generally regarded as a core management instrument. The administrator has agreed to forward the outcome of the previous 2 quality assurance surveys to CSCI when they become available. The few staff that has received recent supervision says that the philosophy of the home and their training needs were not discussed. No one received a copy of his or her supervision notes. There are some concerns regarding safety that have been identified throughout the report. Not all the requirements of the previous site visit have been met. The action plan required of that report did not provide detailed timescales for completion of the outstanding work. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.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 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 X 2 2 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 1 2 1 1 3 1 3 1 STAFFING Standard No Score 27 1 28 3 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 1 2 X 3 1 X 1 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 24 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 OP3 OP4 Regulation 14(1) (c)(d) Requirement The registered person must evidence that there is consultation regarding the assessment with the service user or a representative of the service user and must confirm in writing to the service user or their representative that the care home is suitable for the purpose of meeting the service users needs in respect to health and welfare. The registered person must make sure that appropriate continence management programmes are followed that ensures residents are enabled where possible to remain continent. The registered person must ensure that lack of sufficient staff does not compromise the meeting of residents assessed needs. Residents must be able to go to bed and get up when they wish. Residents must be able to wear their day clothes during the waking day. DS0000028005.V308376.R01.S.doc Timescale for action 24/08/06 2 OP8 12(1-4) 24/10/06 3 OP8 12(1-4) 24/10/06 4 5 OP14 OP14 12(2&3) 12(2&3) 24/08/06 24/08/06 Hawkesgarth Lodge Nursing & Residential Home Version 5.2 Page 25 6 7. OP15 OP19 12(1) (a & b) 23(4(a)) Residents must be given sufficient time and assistance to take their meals and drinks. The registered person is required to submit a plan with timescales to the Commission detailing the arrangements to provide suitable smoking areas for those service users who wish to smoke. Previous timescale not met. 24/08/06 30/11/06 8. OP19 23(2) (b-d) 9. OP21 23(2(j)) 13 (5) The registered person must submit a maintenance programme including timescales in respect to the interior and exterior of the home being brought to a good state of repair, furnishing and décor. The plan must show how this will be maintained. The registered person is required to submit a plan with timescales to the Commission detailing the arrangements to provide sufficient bathing or shower facilities. Previous timescale not met. 30/11/08 30/11/06 10 OP26 12(1)(a) and 16 (2)(j&k) 11 12 OP27 18(1)(a) and 18(3) 13(6) 18(1)(a &c) OP30 The registered provider must ensure that the home is kept clean and free from offensive odours at all times and that policies and procedures are in place and followed in respect to clinical waste disposal. The registered person must ensure that there are sufficient staff on duty at all times. The registered person must ensure that all staff receive appropriate induction and foundation training and that an on going training programme is maintained that will ensure staff have appropriate training and guidance to undertake their role DS0000028005.V308376.R01.S.doc 24/08/06 24/08/06 30/09/06 Hawkesgarth Lodge Nursing & Residential Home Version 5.2 Page 26 13 OP33 24 in the service. The quality assurance monitoring 30/10/06 undertaken by the service must show how its outcomes are actioned. The registered person must ensure that staff receives appropriate supervision. 30/11/06 14 OP36 18 15 OP38 23(4(c (i)) The registered manager must ensure that fire doors are not held open by unauthorised means. Previous timescale not met 24/08/06 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 OP28 Good Practice Recommendations The registered person should encourage staff to achieve NVQ level to in order that at least 50 of care staff holds this qualification. The registered person should remove all ’baffle door handles’ from resident’s bedroom doors. The registered person should ensure that the home has an open and positive atmosphere. 2 3 OP24 OP32 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V308376.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 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. 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