Inspection on 20/06/07 for Hawksbury House

This inspection was carried out on 20th June 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.

Other inspections for this house

Hawksbury House 11/12/06

Hawksbury House 05/01/06

Hawksbury House 28/02/05

Hawksbury House 03/11/04

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Hawksbury House Kellfield Avenue Low Fell Gateshead Tyne & Wear NE9 5YP Lead Inspector Irene Bowater Key Unannounced Inspection 20th June 2007 09:00 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 Hawksbury House DS0000007379.V336628.R02.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. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawksbury House Address Kellfield Avenue Low Fell Gateshead Tyne & Wear NE9 5YP 0191 482 1258 0191 482 5158 hawksburyhouse@aol.com 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) Mr John Henry Beckett Mrs Jacqueline Murray, Mrs Freda Agnes Beckett Mrs Jacqueline Murray Care Home 35 Category(ies) of Dementia - over 65 years of age (10), Mental registration, with number disorder, excluding learning disability or of places dementia (1), Old age, not falling within any other category (35), Physical disability over 65 years of age (4), Sensory Impairment over 65 years of age (1) Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th December 2006 Brief Description of the Service: Hawksbury House is a large, adapted two-storey house with an extension. It is situated in a quiet residential area of Low Fell close to all local amenities and a short drive from Gateshead, Newcastle and the Metro Centre. The building comprises of three double bedrooms and twenty-nine single bedrooms, many with en-suite toilet facilities. All rooms are suitably furnished and have an emergency call system. A passenger lift is available to service the two floors. The Home has wide doors and corridors to allow easy access for wheelchair users, with the exception of a short area of corridor leading to the main ground floor lounge, which is slightly narrower, but still allows access. The home has two lounges, a lounge/dining room, a separate dining room, and a hairdressing room. There are well-maintained gardens to the front and rear of the home and adequate car parking facilities. Staff provide personal care for up to 35 older people, some of who have specific and complex needs. Nursing care is not provided. The statements of purpose and service user guide are not up to date or readily available in the home. There are extra charges for newspapers, hairdressing, chiropody, optician and dental care. The fee rates vary from £284 to £365. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Before the visit: We looked at: • Information we have received since the last visit on 11 December 2007 • How the service dealt with any complaints and concerns since the last visit • Any changes to how the home is run • The provider’s view of how well they care for people • The views of people who use the service and their relatives, staff and other professionals The Visit: An unannounced visit was made on 20 June 2007 During the visit we: • Talked with people who use the service, relatives, staff, the manager and visitors • Looked at information about the people who use the service and how well their needs are met • Looked at other records which must be kept • Checked that staff had the knowledge, skills and training to meet the needs of the people they care for • Looked around the building to make sure it was clean, safe and comfortable • Checked what improvements had been made since the last visit We told the manager what we found. What the service does well: The staff collects information together about the person before anyone moves into the home to make sure they can meet their needs. Staff involves the residents, their representatives and other professionals in the care planning which makes sure their needs can be met. The staff have formed good relationships with the residents and make sure their rights to privacy and dignity are met. They work hard to promote residents independence at all times. Comments from the surveys and from discussion with residents on the day included the following: “I am always kept informed about everything that happens in the home”. “The staff show patience and understanding”. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 6 “The care and support is first class, meeting the expectations of the choice made”. “I am very satisfied with the care and attention”. “The home is clean, tidy and free from any smell”. “It does what it says and takes good care of the people”. “A comfortable, understanding and caring home”. “The manager and the staff are very competent, patient and professional”. “The food is good”. “I get plenty to eat and choose how I spend my day”. “First class food”. “Plenty to do”. “Good social activities and outings”. “I like living here”. “We know if we are unhappy they will soon sort things out”. Visitors are made welcome and there are good links with the local community. Residents and relatives said they would be able to use the complaints procedure if they had a concern. Staff work hard to provide activities inside and outside of the home. The home is well maintained and a pleasant, comfortable place to live. The staff receive the training they need to care for the residents needs. A number of staff have worked together at the home for a long time. They said they get plenty of support from the senior staff and enjoy working at the home. Residents personal moneys are looked after safely. All of the staff are enthusiastic and have created a positive and happy atmosphere in the home. What has improved since the last inspection? The home continues with the maintenance and redecoration on a rolling programme. The contracts have been amended so that residents know what their rights and obligations are. Improvements have been made to the ordering administration and disposal of medication. Staff continue with training so that they can meet individual residents needs. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hawksbury House DS0000007379.V336628.R02.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 Hawksbury House DS0000007379.V336628.R02.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): 1,2,3. (Standard 6 is not applicable to this service.) Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents are not given up to date information about the service provided. The rights and obligations of both parties are not clear to enable prospective residents make informed choices. The admission assessments and procedures ensure the residents care needs will be met. EVIDENCE: The home has a Statement of Purpose and Service User Guide. Both the documents need to be amended and brought up to date. The information refers to the previous Registered Homes Act of 1984 and to inspectors who no longer work for the Commission. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 10 Information about the home and the terms and conditions are available. The writing is now in large print, picture style or easy to understand. Each resident is given a contract, which sets out the charges and fee rates. The contract includes the provision of food, light, heat, laundry and personal care. The charges are to be paid in advance and these will remain the same unless 28 days written notice is given or both parties amend the agreement. Before moving into the home residents have an assessment of need, which is completed by, care managers and the home manager. Should the resident be privately funded the home manager uses their own assessment tools. This information is needed so that residents can receive the correct level of care as soon as they are admitted. Five care plans were inspected. Evidence was seen of appropriate Care Management assessments, pre-admission and admission assessments by the home. Risk assessments were also in evidence and care plans are drawn up from this information. Hawksbury House DS0000007379.V336628.R02.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): 7,8,9,10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The care planning systems do not provide staff, residents and their representatives with the information they need to make sure residents individual needs are met. Health and personal care is well met so that the care people receive is based on their individual needs. Robust systems for the administration of medicines are in place. Further improvements will make sure that residents receive their medication safely. A good level of personal support is in place, which promotes peoples rights to privacy and dignity. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 12 EVIDENCE: Each resident has a care plan that has been developed with the help of information gathered before they came to live in the home. Risk assessments are in place for falls, moving and handling and pressure sore care. Information is also gathered about residents social care needs so that the staff can help them maintain their lifestyles whilst living in the home. Care plans showed that they were not fully completed, dated and signed. Many have not been reviewed and up dated for a year. This means accurate information that residents care needs are met is not available. Risk assessments and evaluations of care were not carried out at least monthly. Residents who may not eat and may exhibit some difficult behaviour did not have care plans to inform staff how to deliver care in a consistent manner. Doll therapy is being tried but staff have little or no knowledge of how this therapy can work. No care plans are available to tell staff what they should do. One resident who has lived in the home for some time has not had her care plan rewritten since admission despite being at risk of pressure damage and falls None of the care plans were detailed about residents social care needs. Previous life histories are not available and the care plans do not reflect a person centred approach to care delivery. Families are sometimes included in regular reviews that are held to establish if needs of the resident have changed. However, where families are not involved this information needs to be noted and reasons documented so that there is a full picture of the resident that will to enable the correct decisions to be made. The good care practices observed throughout the inspection were not evidenced through the care plan documentation. The residents have access to all NHS facilities to ensure their healthcare needs are met. There are regular visits from GP’s including, opticians and chiropody services. Advice and support is available from other healthcare professionals when required such as the Continence Advisor, and tissue viability nurse. Since that last inspection the home has changed the systems for the safe administration of medicines. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 13 The home uses a monitored dosage system for administration of medicines that are prescribed to residents. This system is designed to minimise the risk of any errors when used correctly. Medicines are put into individual blister packs by the pharmacy and sent to the home every month. The senior care staff and manager administer medication to residents and staff have completed a “Safe Handling of Medicines” course. Records are in place for all medicines received, administered and disposed of. An audit of Controlled Drugs and the Medicine Administration Records (M.A.R.) showed no discrepancies. Handwritten directions did not have any witness signatures, which would make sure there had been no error in transcribing. Resident identification was not available on all of the M.A.R. sheets. A check of the Controlled Drugs found no discrepancies. The book used to record Controlled Drugs is an ordinary hard backed book without pre numbered pages. Residents spoken to felt that they are treated with respect and their right to privacy is upheld. Residents spoke about their personal wishes and preferences, which are respected by staff. Examples include locking their bedroom doors, receiving their mail, being addressed by their preferred name and being able to go wherever they wish inside and where possible, outside of the home. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A range of social activities is provided which offer stimulation and interest for residents living in the home. Support from relatives and representatives provide residents with good opportunities to maintain their previous lifestyles. Residents are well supported to make choices and take control over their lives. Choices of nutritious and appetising meals are available to ensure individual dietary needs and preferences are met. EVIDENCE: Residents are involved in planning activities in the home. The notice board displays past and future events including visits to Saltwell Park, Baltic Centre and a visit to Harry Ramsden’s for fish and chips. Residents enjoy visits from a visiting artist and aroma therapist. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 15 The local schools visit regularly to gain information about a historical programme they were doing and also to entertain the residents. There are close links with the local church groups with regular services with residents attending lunch clubs. The staff support anyone who wishes to go out locally to do shopping. Should anyone prefer their own company this is respected by staff and they can spend time as they wish. A newsletter is produced to inform residents of activities being held in the home. Visitors were seen to come and go throughout the inspection. Staff spent time with them and shared information about their relative if necessary. Comments from relatives included: Staff are always friendly Always something going on in the home. They bring in lots of entertainers and have regular day trips Good social activities and outings Whatever residents are capable of for example knitting, reading their needs are catered for The residents said that they are able to spend their days as they wish. They confirmed that they could get up and go to bed when they want and mealtimes are flexible. Information about advocacy is readily available but all of the residents said that the manager would “always sort anything out”. All of the residents have brought small items with them making their own bedrooms homely and personalised. The inspector joined the residents for the lunchtime meal. Tables were very pleasantly set with condiments, serviettes and sugar bowls. Hot and cold drinks were offered and the meal was well presented with vegetables served from tureens and gravy in gravy boats. Alternative choices were served to those people who requested them. Staff were attentive and offered assistance to those who needed it, in a discreet, courteous and unhurried manner. The environment and the atmosphere were sociable and pleasant. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 16 Residents said: “Food is always good”, “It’s lovely” “I always get plenty to eat”. Comments from relatives included: Good food Very good home cooked food. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The complaints procedures are clear. Residents and relatives are confident that their views are listened to and acted upon. Arrangements for the Protection of Vulnerable Adults are satisfactory and protect residents from harm. EVIDENCE: The home has clear complaints policies and procedures, which are displayed, in the home. The records showed that complaints are documented appropriately and include outcomes with signatures obtained to confirm the complainant’s satisfaction of the outcome. There have been two complaints received since the last inspection and they have been resolved at home level. All of the residents spoken with said they had nothing to complain about but were very clear that the manager would deal with any issue immediately. Within the complaints documents are many compliment letters and cards from relatives to the Manager and staff for the care and support given to residents and relatives, both during their stay in the Home and after death. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 18 The Home has a Protection of Vulnerable Adults Procedure (POVA) in place and a copy of the Local Authority’s Procedural Framework for the Protection of Vulnerable Adults, is available to staff. The staff complete training with an external training agency. Training with the local authority is to be sourced for the staff. There have been no Safeguarding Alerts made to either Local Authority or to the Commission for Social Care Inspection Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 19 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): 19.29,21,24,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is clean, warm, well maintained and suitably decorated so that the residents have a homely and safe environment to live in. EVIDENCE: This is a large, adapted two-storey house with an extension.Ther are two lounges, a lounge/dining room, a separate dining room, and a hairdressing room. There are well-maintained gardens to the front and rear of the home and adequate car parking facilities. There is an ongoing redecoration programme and the furnishings and fitting are of a good standard. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 20 Since the last inspection there was a fire in the upstairs lounge This was well managed by the staff and no harm came to anyone. The lounge however was extensively damaged and work is to start to refurbish this room. It is currently locked and out of use. Bedrooms have en suite facilities. Only one bathroom on the ground floor is used for all the residents as this has an adapted bath. The other bathing facilities including the shower are not used. All of the bedrooms inspected were clean, decorated and furnished to a good standard. Many of the residents have brought small items of furniture and keepsakes with them making the rooms highly individualised. Bedrooms are only shared in limited situations and only with agreement with the people using the service. They are always given the choice to move to a singe room when one becomes available. The home is well lit, clean and tidy and fresh smelling. Staff were observed to follow infection control procedures. The laundry is small but clean and organised. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The current staffing levels is sufficient to meet the residents’ needs. A training programme is in place to make sure staff have the competence to care for the residents needs. There are robust recruitment policies in place. Unless they are always followed the manager cannot be sure that residents are protected from harm EVIDENCE: The rota reflects the staff on duty over the twenty-four hour period. The day shift starts at 07:30 am until 16:00 and the late shift starts at 13:00 until 10:15 pm. The night shift starts at 10:15 until 08:30 am. There is an overlap of staff during the twenty-four hour period to make sure residents needs are being met. The home benefits from a stable staff team who have worked at the home for some time. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 22 The registered manager is supernumerary. The home has a deputy manager and senior care staff. Ancillary staff includes cook, kitchen assistant, laundry, domestic, maintenance and administration. Comments received from relatives included: They are extremely caring and thoughtful. The staff are excellent at accommodating different needs Residents said: They are very good Everyone looks after me. Over 77 of staff have completed NVQ level 2 training. Four staff files were inspected. Job descriptions and roles are clear and each file had an application form completed. There was evidence of Criminal Record Bureau checks, Protection of Vulnerable Adult checks, and proof of identity. Two of the files did not have two references. This was because the staff had previously worked in the home, had left and re employed. The staff complete an induction programme and have a training and development file. There is a training and development plan and programme in place. Records showed that staff have received food hygiene, infection control, moving and assisting and health and safety training. The staff have also received training in Safeguarding Adults, safe administration of medicines and positive dementia care. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 23 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. The home has an experienced manager who provides leadership. This ensures the home is run in the best interests of people using the service. Clear systems for consultation and quality monitoring make sure that the views of residents are sought and acted upon. Residents personal accounts are managed to ensure their best interests are protected. Without up to date training and clear record keeping the staff cannot be sure that residents are fully protected. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 24 EVIDENCE: The registered manager has a Registered Nurse qualification, Registered Managers Award and NVQ level 4.She has many years experience in caring for older people. She attends training to update her knowledge and skills whilst managing the home. The responses from the comment cards and from discussions on the day confirmed that she is approachable, available and supportive at all times. A quality assurance survey has been completed which shows that residents are more that satisfied with the service provided. Regular staff and residents meeting are held. The minutes are recorded and displayed on the notice board. Concerns have an action plan showing how things are going to be put right. An audit of five residents personal allowances was carried out. There were no discrepancies. All had individual records and separate wallets containing their money. The records are dated with two signatures and receipts are available for all transactions. Evidence was seen in the records and staff confirmed they had received training in health and safety issues such as, food hygiene, first aid, infection control, moving and handling and COSHH (Control of Substances Hazardous to Health). Accidents are recorded and the manager carries out an analysis to examine any trends. There was no evidence that staff had received fire training at the required intervals of three monthly for night staff and six monthly for day staff. An immediate requirement was issued which required that all staff receive the appropriate training within forty-eight hours. Information was received within the timescale that this training had been completed There is a fire risk assessment and a fire inspection was carried out January 2007 following the fire in the upstairs lounge. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 25 In house health and safety checks are carried out weekly. Water temperatures are recorded to ensure temperatures of 44 C is not exceeded. External contract certificates are up to date. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 26 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 2 2 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 27 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 OP1 Regulation 4,5 Requirement The registered persons must make sure that the Statement of Purpose and Service User Guide are reviewed. The Guide needs to be in plain English and in a format suitable for the intended residents. Timescale of 01/04/07 not met. The registered persons must ensure that the care plans are reviewed by care staff at least monthly and updated to reflect changing needs. Timescale of 01/04/07 not meet The registered person must ensure that any hand written directions on the Medicine Administration Record has two signatures Timescale of 31/01/07 not met. The registered persons must ensure that there is identification of residents on the Medication Administration Records. The registered person must ensure that the flooring by the kitchen is repaired. DS0000007379.V336628.R02.S.doc Timescale for action 01/10/07 3. OP7 13,15 01/09/07 4. OP9 12,13,17 01/08/07 5 OP9 12,13,17 01/08/07 6 OP20 23 01/08/07 Hawksbury House Version 5.2 Page 28 6 OP29 7,9,19 7 OP38 23 The registered person must 01/09/07 ensure that two written references are obtained for every member of staff working in the home The registered person must 01/08/07 ensure that fire training and fire drill are carried out according to requirements. Records of fire training must include the dates, names and signatures of attendees with the name and signature of the accredited trainer. 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 OP1 OP20 OP21 Good Practice Recommendations The registered manager should provide a bound book with pre numbered pages for the recording of Controlled Drugs. The fire damaged lounge and corridor should be refurbished as soon as possible. The registered manager should review the assisted bathing facilities in the home. Hawksbury House DS0000007379.V336628.R02.S.doc Version 5.2 Page 29 Commission for Social Care Inspection South Shields Area Office 4th Floor St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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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