Inspection on 04/01/06 for Hawkesgarth Lodge Nursing & Residential Home

This inspection was carried out on 4th January 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 &... 18/08/06

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 Mrs Rosalind Sanderson Unannounced Inspection 10:00 4 January, 2006 th 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.V264737.R01.S.doc Version 5.0 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.V264737.R01.S.doc Version 5.0 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 - over 65 years of age (40), Mental registration, with number Disorder, excluding learning disability or of places dementia - over 65 years of age (40) Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 60 years plus Service users to include 40 (DE(E)) and up to 40 (MD(E)) up to a maximum of 40 service users. 13th July 2005 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 suffer from a dementia. Hawkesgarth lodge is located in Hawsker a hamlet south of Whitby and is situated in its own grounds. The accommodation provided is in single and double rooms over two floors and there is a passenger lift giving access to the first floor. There is an enclosed garden area and ample private parking for visitors and staff. The home is owned by European Care (UK) Limited and was registered in 2002. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted for five hours including preparation time. The focus of the inspection was on the key standards not assessed at the last inspection and the shortfalls in the standards that were identified at the last inspection. Service users private accommodation was looked at with their permission, where possible, and all communal areas of the home were inspected. Records relating to service users, staff and health and safety were looked at. Service users, their relatives and staff were spoken with during the inspection and time was spent observing the daily routines of the service users and staff. Comments received are included in the summary and body of this report. A member of staff was available to assist in the inspection process and the registered manager was available towards the end of the inspection and for the feedback. What the service does well: What has improved since the last inspection? The manager has been successful with his application to become registered. Since the last inspection, systems have been improved to ensure that medication is handled and recorded correctly so that service users receive medication safely. Mealtimes have improved so that there is flexibility for service users. A service user was seen having breakfast at 10:30 as he had had a lie in. A cooked breakfast is also available on request. Wheelchairs in the home are used safely. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 6 What they could do better: Some requirements from the last inspection had not been addressed. These include the following: • • • • Fire doors continue to be held open by unauthorised means. The floor covering in the dining room of the Lodge had not been repaired/replaced. A suitable area for the use of smokers had not been provided. The manager had not supplied the commission with a plan to show how the shortfalls in bathing facilities would be addressed. • In addition the following was noted: • • • There is not a choice of food available at each mealtime. The cook is not aware of individual service users dietary requirements. There were no risk assessments in place for bed rails that were in use and no system for checking their continued safe use. • These issues were discussed with the manager at the time of the inspection and an official notice left to require that action be taken immediately with regard to the fire doors. 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.V264737.R01.S.doc Version 5.0 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.V264737.R01.S.doc Version 5.0 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): Standard 6 is not applicable. The remaining standards were not assessed at this inspection. EVIDENCE: Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9,10 Service users are cared for respectfully and safely and their privacy is respected. EVIDENCE: Medication systems showed that all medication is stored, handled and administered safely. Since the last inspection recording of administered drugs has improved and there was evidence on the medication administration records to show that entries are made using the appropriate code when medication is refused. The controlled drug book was clear and up to date with all stock balances correct with the entries reconciling with the stock held. Service users were free to walk around the home safely and staff were observed speaking clearly to them and giving them opportunity to respond. One service user commented, ‘I love it here the staff are good, I will stay here until the end of my days’ Another said, ‘They (the staff) want me here, I feel special’ Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 10 Relatives spoken with said, ‘You just have to look at ……. to see how happy she is and she is always clean and well dressed. The best thing is that she can move around the home freely and she is safe’ Relatives stated that they are always able to see their relative in private if they wish and they are always made to feel welcome in the home. Comments received included, ‘We are always kept fully informed about how……..is doing. When we come to the home the staff always tell us how ……has been doing.’ Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12&15 Service users live fulfilling, busy lives. A wider choice of menu at mealtimes and improved systems for informing staff about dietary needs would benefit service users. EVIDENCE: The home employs an activities organiser who was on duty at the time of the inspection. She was enthusiastic about her role and able to explain what activities the service users were able to take part in. On the day, service users were observed carrying out embroidery and they were very engrossed with this. Staff are employed in sufficient numbers to allow one to one attention for those service users who prefer this. All the staff were involved in occupying service users. Service users were calm and occupied. Mealtimes are flexible to suit the needs of the service users; one had breakfast at 10:30 as he had just got up. Since the last inspection, a cooked breakfast is available on request to increase the choice for service users. The kitchen staff were not fully aware of service users dietary needs and stated that a choice of menu was not offered at the main meal. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 12 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): These standards were not assessed at this inspection. EVIDENCE: Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 13 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): 19,21 Environmental standards need addressing to ensure the home is safe and homely. EVIDENCE: Service users bedrooms are personalised with items that reflected their past and present lives. Some of the bedrooms are shared and there was appropriate screening in place to ensure privacy. There are plans for a refurbishment of the home that will ensure the areas of the home that require re decoration are attended to. The following issues regarding the premises and facilities were identified and need to be addressed: • Fire doors were held in the open position by the use of wedges or chairs. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 14 • The home has two operational bathing facilities and two assisted showers. This leaves a shortfall of one bath/shower facility for forty service users. The floor covering in the dining room of the Lodge is torn and poses a trip hazard for service users. The designated smoking area is in the entrance hall of the home. • • Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 15 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): 28&29 Service users are cared for by staff that are safe to do so. EVIDENCE: Staff records that were looked at showed that pre employment checks are carried out for all staff that wish to take up employment at the home. New staff are subject to induction and records seen confirmed this. Staff spoken with were knowledgeable about individual service users needs and wishes. Staff felt there were sufficient numbers on duty at all times and they had time to carry out their roles. Observation on the day confirmed this and staff had ample time to spend with service users. Staff have received training relevant to their role and all mandatory training. However the home has only achieved 5 of staff qualified to NVQ level 2. There are plans for most of the care staff to start this training this month. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 16 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): 31,32,33,38 Health and safety issues identified need addressing to ensure that the home remains safe. EVIDENCE: The manager is a qualified nurse and has recently been successful in his application to become registered manager of the home. He has a number of years experience in caring for people with mental health needs. Staff appreciate his management style and commented that changes he has implemented focus around the service users needs, enabling them to carry out their roles more efficiently. The manager carries out regular audits within the home to ensure consistency of the service offered, however the views of service users and other stakeholders are not sought on a regular basis. This would better inform the home of how they are performing. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 17 The following issues require attention to ensure continued safety: • • Fire doors were held in the open position by the use of wedges or chairs. There were no risk assessments in place for those service users that require the use of bed rails. There were no systems in place to ensure that their safety is checked on a regular basis. The floor covering in the dining room of the Lodge is torn and poses a trip hazard for service users. The designated smoking area is in the entrance hall of the home and this poses a fire risk and is not pleasant for the people living at the home. • • Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 18 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 X 14 X 15 1 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 X 1 X 1 X X X X X STAFFING Standard No Score 27 X 28 2 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 X X X X 1 Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 19 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 OP15 Regulation 16(2(i)) Requirement The registered manager must ensure that: • A choice of food is available for service users at all mealtimes. Timescale for action 28/02/06 2. OP19OP38 3. OP19OP38 4. OP21 That the cook is provided with a list of service users likes, dislikes and dietary requirements. 23(4(c (i)) The registered manager must ensure that fire doors are not held open by unauthorised means. Previous timescale not met 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 not met. 23(2(j)) The registered person is required to submit a plan with timescales to the Commission detailing the arrangements to provide bathing or shower facilities in sufficient numbers for service users use. • DS0000028005.V264737.R01.S.doc 04/01/06 31/03/06 31/03/06 Hawkesgarth Lodge Nursing & Residential Home Version 5.0 Page 20 5. OP38 13(4(a&c) The registered manager must: • Make arrangements to ensure that the tear in the floor covering in the Lodge dining room does not pose a risk to service users and staff. • Ensure that a risk assessment is in place for all bed rails in use and that they are checked on a regular basis to ensure they are used safely. 31/01/06 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. 2. 3. Refer to Standard OP28 OP31 OP33 Good Practice Recommendations The manager should continue to encourage staff to achieve NVQ level to in order that at least 50 of care staff hold this qualification. The registered manager should register with a training provider in order that he achieves the Registered Managers Award. It is recommended that the views of all stakeholders in the service are sought to inform the manager of how well the service is doing. Hawkesgarth Lodge Nursing & Residential Home DS0000028005.V264737.R01.S.doc Version 5.0 Page 21 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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