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Inspection on 26/04/07 for Hawkesgarth Lodge Nursing & Residential Home

Also see our care home review for Hawkesgarth Lodge Nursing & Residential Home for more information

This inspection was carried out on 26th April 2007.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The individual and group activities that are provided by the activities organiser are well received. One relative said, `The person in charge of coordinating social activities is doing a tremendous job.` The staff team are enthusiastic and committed and have some good ideas for improving services. One of these ideas was to develop the garden area to include a sensory garden. Relatives feel welcome when they visit the home and appreciate the staff team. Comments received include, `The staff employed show interest and care for the residents`.

What has improved since the last inspection?

Since the last inspection a new manager has been recruited to the home. Comments received from relatives and staff indicate that they have high hopes from her appointment. These include, `Hopefully the appointment of a new manager will improve communication between the home and relatives and improve staff moral` A staff member said, `Although the manager has just started she seems to be working hard to resolve issues, I feel positive about the future` Staffing levels have increased so that more staff are available at all times during the day. Fire doors are kept closed or held open by approved means. This goes towards protecting people from the risk of fire. Some elements of the environment have been improved with redecoration and new flooring to communal corridors. This has gone some way to enhance the environment for people living there.

What the care home could do better:

In order that people`s needs are fully met at Hawkesgarth Lodge additional staff training must be provided to ensure that staff have the necessary skills to look after this client group. The staff must receive specialist dementia care training with specific reference to communication, dietary needs, continence promotion, and activities suitable for the client group. Promotion of continence will help eliminate the strong smell of urine in some parts of the building. Staff must develop activities for people and see this as an important part of their role in caring for these people and not just the role of the activities organiser. The environment requires some major work carrying out and firm plans must now be forwarded to the Commission for Social Care Inspection along with time scales for completion. This includes the provision of sufficient bathing facilities and the provision of a suitable and acceptable area for people that wish to smoke. The system for cancelling call bells in one wing of the home must be reviewed as a matter of urgency so that staff are provided with the correct safe means of cancelling the call bells. The Quality assurance system must be developed so that it becomes a useful exercise. Results from this must be communicated to people living at the home, staff, relatives and other interested parties. The results must also beused to form a development plan for the home. This will show that the organisation is listening and acting on what people say.

CARE HOMES FOR OLDER PEOPLE Hawkesgarth Lodge Nursing & Residential Home Station Road Hawsker Whitby North Yorkshire YO22 4LB Lead Inspector Mrs Rosalind Sanderson Key Unannounced Inspection 26th April 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.V335037.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.V335037.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.V335037.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. Date of last inspection 18th August 2006 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. Information received from the home on 30/04/07 advises that 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.V335037.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The key inspection has used information from different sources to provide evidence for this report. These sources include: • • • • • Reviewing information that has been received about the home since the last inspection. Information provided by the deputy manager on a pre inspection questionnaire; Comment cards returned from 17 relatives, 5 service users (completed with assistance), 3 staff, 2 GPs and 1 care manager. A visit to the home carried out by two inspectors. Evidence gained from the use of an observational tool developed to help inspectors gain an insight into services that people with a dementia receive. A site visit was carried out and lasted for five hours. Two relatives and eight staff were spoken with. Records relating to service users, staff and the management activities of the home were inspected. During the visit one inspector spent a period of time observing wellbeing, engagement and interaction of service users in a communal area. This helped the inspector to gain an insight of what life is like at Hawkesgarth Lodge for the people that live there. The manager, staff and administrator assisted the inspectors during the day. The manager and administrator were given feedback from the inspection at the end of the day. What the service does well: The individual and group activities that are provided by the activities organiser are well received. One relative said, ‘The person in charge of coordinating social activities is doing a tremendous job.’ The staff team are enthusiastic and committed and have some good ideas for improving services. One of these ideas was to develop the garden area to include a sensory garden. Relatives feel welcome when they visit the home and appreciate the staff team. Comments received include, ‘The staff employed show interest and care for the residents’. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: In order that people’s needs are fully met at Hawkesgarth Lodge additional staff training must be provided to ensure that staff have the necessary skills to look after this client group. The staff must receive specialist dementia care training with specific reference to communication, dietary needs, continence promotion, and activities suitable for the client group. Promotion of continence will help eliminate the strong smell of urine in some parts of the building. Staff must develop activities for people and see this as an important part of their role in caring for these people and not just the role of the activities organiser. The environment requires some major work carrying out and firm plans must now be forwarded to the Commission for Social Care Inspection along with time scales for completion. This includes the provision of sufficient bathing facilities and the provision of a suitable and acceptable area for people that wish to smoke. The system for cancelling call bells in one wing of the home must be reviewed as a matter of urgency so that staff are provided with the correct safe means of cancelling the call bells. The Quality assurance system must be developed so that it becomes a useful exercise. Results from this must be communicated to people living at the home, staff, relatives and other interested parties. The results must also be Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 7 used to form a development plan for the home. This will show that the organisation is listening and acting on what people say. 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.V335037.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 3. 6 is not applicable. People who use the service experience adequate quality outcomes in this area. People’s basic care needs are assessed prior to admission to the home and they receive sufficient information about the services provided. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: The service usually encourages prospective residents and their representatives to visit the home prior to admission to look around and meet the staff. One relative spoken with was satisfied with the information that they received prior to their relative moving in to the home. A comment received from a relative indicated that this is not always the case with one person saying, ‘I did not receive any information at all about the home or what it has to offer.’ Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 10 The service undertakes a pre-admission assessment on prospective resident’s that examines their physical and cognitive needs, however there is little evidence that emotional or spiritual needs are considered. There is no evidence that service users or their representatives agree the assessment or have continued involvement. 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.V335037.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience poor quality outcomes in this area. The health and personal care that people receive is not based on their individual needs and does not promote dignity, respect and privacy. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: All residents have a detailed care plan that sets out the care to be provided. Regular recorded reviews are undertaken. However there is evidence that these documents are not working tools. Daily records and carer records are kept separately and only filed within the care plans when complete. Care staff commented, ‘When I first started no one told me that I should read the care plans, I only found this out some time later’ and ‘Although we are made aware of service users needs when they are admitted, we are not always told if an existing service users needs change’. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 12 Although staff numbers have increased since the last inspection observation showed that continence promotion remains a low priority. During a period of sustained observation no person was asked if they would like the toilet or encouraged to use the toilet. All service users in the lounge were sat on incontinence type chair pads and many cushions were missing from the chairs. These were outside drying. There was a strong smell of urine in the entrance hall, many bedrooms and some communal areas. A relative reported ‘When we visited ………their night dress and night pad were dripping in urine, we had to help them to change.’ During the visit one person was sat in their nightclothes until lunchtime. Nobody offered to help this person get dressed. Male service users were being shaved in the lounge area and sat with towels around their necks waiting their turn. One member of staff was seen taking a comb from her pocket to use on a number of service users hair. Application of creams was also carried out in the lounge. Some of these tasks were completed with no conversation with the service user. Nutritional risk assessments were in place for all service users. However staff did not give assistance to service users to enable them to take sufficient diet and fluids even when people were at risk nutritionally. Drinks and food were placed in front of people and then removed, untouched in some cases, without the offer of assistance. Relatives also commented on this with one saying, ‘Food is often cold and I find their cup of tea on the side untouched and cold’. There were periods of time when there were no care staff in the lounge area although information had been received that two people were receiving one to one supervision. A relative had passed comment that often there are no care staff in the main lounge area and that this concerned them. There was no reference in the care plans to oral hygiene needs. People were not given the opportunity to clean their teeth after meals. A staff member had commented in the survey, ‘Oral hygiene is extremely poor. Often dentures are not soaked and left in people’s mouths overnight. Many people are suffering from poor oral hygiene’ Medication procedures ensure that people receive their medication safely. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 13 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 and 15. People who use the service experience poor quality outcomes in this area. Social and recreational activities do not meet individual and collective needs. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: There is an activities organiser employed at the home who does some good work individually and in groups with service users. One relative commented, ‘The person in charge of coordinating social activities is doing a tremendous job.’ Outings are arranged when possible and group activities within the home take place. Information on community events is obtained and where possible small numbers of people are taken to these. On the inspection day, activities were organised on an individual basis. Care staff do not appear to take an active part in the social activities at the home. One relative had said, ‘Residents benefit from social activities and perhaps more could be done in this area’. Care staff were observed during their routines speaking politely to people. However communication between staff and people was not always beneficial. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 14 Sometimes staff asked a question but did not wait for a response or asked questions that did not need a response such as, ‘You’re alright aren’t you?’ or ‘You’ve had enough, then?’ whilst taking their meal away. One service user was asleep when a staff member approached and said, ‘I have a cup of tea for you’. One service user was obviously distressed and anxious but staff made no attempt to engage with them during the morning. People using the service and their representatives are not always consulted on how the home can work to provide them with a lifestyle that is suited to them. Relatives reported that, although they are always made to feel welcome they do not know what is going on in the home. Residents meetings are not held at this time. Quality assurance surveys had been carried out but the results had not been published or acted upon. The home is at this time without a full time cook. Although menus provided would suggest that a choice of food is available at mealtimes, it is unclear whether this choice is actually offered to service users. People that require a soft diet are served this liquidised and all mixed together. This is neither appealing, appetising and does not address individual food preferences. Staff assist people to take their diets in some cases. However in some instances this is not done in a way that promotes dignity and respect. Staff were observed assisting more than one service user at a time and often taking away food from people who have not eaten anything or been offered any assistance to do so. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 15 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 and 18. People who use the service experience good quality outcomes in this area. People feel able to express concerns and they feel safe. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Relatives said that they felt they were able to express their views and concerns and they would be listened to. The service has a complaints procedure that is clearly written and easy to understand. The complaints procedure is supplied to everyone living at the home and is displayed in a number of areas within the service. Relatives understand how to make a complaint. The home keeps a record of complaints made. However details of the investigation and any actions taken is not kept. There have been three complaints received since the last inspection. Details of the investigation and findings had been forwarded to the Commission for Social Care Inspection. These had been investigated appropriately. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 16 The policy and procedure for Safeguarding Adults has been reviewed and amended to ensure that they are in line with the Local Authority procedures. Staff working at the home know when incidents need reporting and who to report them to. There has been one Adult Protection issue at the home that was appropriately referred and handled correctly. Staff have received training in how to protect people in their care. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 17 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 and 26. People who use the service experience adequate quality outcomes in this area. People would benefit from improvements to the environment. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: There have been improvements to the environment made by decorating some communal areas and individual bedrooms. New flooring has been provided to corridors. However there is still a strong smell of urine in some areas. A smoking room had been provided for people who wish to smoke. This had not been well utilised and the situation remains that people are smoking in the entrance hall of the home. All visitors to the home and people living there use this area. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 18 Attempts had been made to clear the gardens and make them more attractive. There are plans to have the gardens tended to professionally. The service has not been provided with additional bathing facilities despite requirements in the last two inspection reports. There is only one bath to service the whole home and on the day of the visit this bath was leaking. The manager stated that additional baths had been ordered and arrangements had been made to have them fitted. It was not possible to give a date for this. Shower facilities are available for people to use in the home if they wish Staff had made suggestions for improvements in their surveys. These included developing the garden area so that people could use it more and possibly having a sensory garden with raised beds. Equipment was seen to be used correctly and safely by staff. It remains outstanding that in one unit in the home there is a problem with cancelling call bells. Reset devices are not available to staff and they have to use matchsticks or hairgrips to cancel the call bells. This affects ten bedrooms in the home. This needs attention so that call bells can be reset correctly. All fire doors were closed or door guards in use to enable them to be held open safely. Fire equipment had been checked. Staff were aware of fire procedures. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. People have access to sufficient numbers of staff but would benefit if staff received additional training. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Staff are recruited following robust recruitment procedures. Generally staff are very committed to their roles and appreciated by residents and relatives. Comments received from relatives include: ‘Most staff are very tactile and caring towards residents’, ‘The staff employed show interest and care for the residents’. There is evidence to show that staff receive induction training and all mandatory training including moving and handling and fire training. All staff receive supervision. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 20 There are currently only 4 of care staff trained to NVQ level 2 or above in care. Further staff are undertaking the qualification and the new manager is encouraging other staff to take up the training. Two members of staff at the home have been trained to deliver the ‘Yesterday, today and tomorrow’ training to care staff. This is a training programme designed to help staff understand the needs of people with dementia. There is an obvious need for staff to receive further training in specialist Dementia Care and communication skills so that they are fully equipped to meet the needs of people at this home. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience adequate quality outcomes in this area. Effective quality assurance systems will ensure that the home is run in the best interests of service users. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: A manager has recently taken up her post at the home. She is experienced and qualified to manage care homes. She has already identified areas for improvement in the home. Relatives and staff have made comments about her appointment. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 22 These include, ‘Hopefully the appointment of a new manager will improve communication between the home and relatives and improve staff moral’ A staff member said, ‘Although the manager has just started she seems to be working hard to resolve issues, I feel positive about the future’. Another said, ‘I feel very optimistic, things are improving and hopefully will continue to improve providing she gets the support from European Care’. Quality assurance within the service consists partly of a questionnaire sent to relatives annually. Although the information from last year had been collated the results had not been published and no action had been taken on issues that had arisen. The administrator said that this was partly due to the staffing problems the home had experienced in the past year. The Quality Assurance tool that the organisation has adopted has not been implemented at this stage. Service users monies are handled appropriately. All health and safety certificates are up to date and procedures are in place to ensure that service users and staff remain safe. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.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 X X 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 3 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 1 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 1 X X X X X X 1 STAFFING Standard No Score 27 3 28 2 29 3 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 1 X 3 X X 3 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.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 OP8 Regulation 12(1-4) Requirement The registered person must make sure that appropriate continence management programmes are followed that ensures residents are enabled where possible to remain continent. Previous timescale of 24/10/06 not met. 2. OP10 12(4(a)) In order that dignity is promoted male residents must not be assisted to shave in the communal areas of the home. A programme of activities must be available in the home to meet individual and collective needs of people. Residents must be able to wear their day clothes during the waking day. Previous timescale of 24/8/06 not met. 11/05/07 Timescale for action 31/05/07 3. OP12 16(2(n) 31/05/07 4. OP14 12(2&3) 11/05/07 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 25 5. OP15 12(1)(a & b) Residents must be given sufficient time and assistance to take their meals and drinks. Previous timescale of 24/8/06 not met. 11/05/07 6. OP15 16(2(i)) People must be given a real choice of what food they would like to eat. This food must be correctly prepared and presented. 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 of 31/3/06 and 30/11/06 not met. 11/05/07 7. OP19 23(2(j))1 3 (5) 31/05/07 8. OP19 23(4(a)) 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 of 31/3/06 and 30/11/06 not met. 31/05/07 9. OP19 23(2)(bd) 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. Previous timescale of 30/11/06 not met. 31/05/07 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 26 10. OP19 16(1) Arrangements must be put in place to ensure that call bells can be cancelled correctly using the correct equipment so that people are able to use these at all times. The registered provider must ensure that the home is kept clean and free from offensive odours at all times. Previous timescale of 24/8/06 not met. 31/05/07 11. OP26 12(1)(a) and 16 (2)(j&k) 31/05/07 12. 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 • Continence promotion. The training must be properly evaluated and staff’s understanding monitored. The newly appointed manager should apply to become registered with the Commission for Social Care Inspection. 30/06/07 13. OP31 8 (1(b)) 26/06/07 14. OP33 24 The quality assurance monitoring 30/06/07 undertaken by the service must show how its outcomes are actioned. Previous timescale of 30/11/06 not met Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 27 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 OP3 Good Practice Recommendations Service users and their representatives should be encouraged to sign the pre admission assessment to show agreement and participation in the process. Written confirmation should be given to the service user and/or their representatives that the home can meet the assessed needs. Details of the outcome of complaint investigations and whether the complainant is satisfied should be recorded in the complaints log. The registered person should encourage staff to achieve NVQ level 2 in order that at least 50 of care staff hold this qualification. 2 OP3 3. OP16 4. OP28 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V335037.R01.S.doc Version 5.2 Page 28 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. 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