Inspection on 05/01/06 for Hawksbury House

This inspection was carried out on 5th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hawksbury House 20/06/07

Hawksbury House 11/12/06

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 Mrs P A Worley Unannounced Inspection 5th January 2006 10:00 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.V262561.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. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 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 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.V262561.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 17/08/05 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. Hawksbury House DS0000007379.V262561.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 was carried out over one day by one Inspector. The majority of residents, some staff, and one visiting relative were spoken to. A sample of records were inspected that included health care assessments and records in the care plans, resident’s finance records of personal allowances, complaints records and staffing rotas. The building was checked to see the facilities and equipment available for residents, and the general maintenance and safety of the property. No requirements were made at the last inspection and the recommendations made in relation to medications have been acted upon. What the service does well: What has improved since the last inspection? A new floor has been laid and some new pictures of interest put on the walls of the recently decorated main dining room, which makes it more homely and inviting. The Dementia Care training previously completed by the Manager and Deputy has been offered to all other care staff. and has been completed by almost all of them. Staff said this training has had a good affect in the way that they now understand better, and are able to provide better care for residents with dementia. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 6 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. Hawksbury House DS0000007379.V262561.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 Hawksbury House DS0000007379.V262561.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): Standards 3 and 4 were assessed and met at the last inspection and although were not fully assessed on this occasion, residents indicated that their needs were still being met to their satisfaction. EVIDENCE: Hawksbury House DS0000007379.V262561.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): 7 & 8. Progress in developing and improving the individual care plan records for residents continues to be made. The health care needs of residents are well met with good documentary evidence to support this. EVIDENCE: The care plans were not assessed in detail but from discussions with the Manager and viewing the records to assess health care evidence, it was clear that further developments to improve the documentation are taking place. A ‘core/assessment form’ has been developed to assist in ensuring that appropriate and specific information is gathered about residents newly admitted to the Home, and input from residents and relatives is sought with this. While the evaluation sections of the plans are completed and up to date, they tend to contain information that only demonstrates the plans are monitored. Evaluations need to review how effective the care plan is for that particular area of need and show where the evaluation has highlighted the need for a Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 10 change in how care is planned. Entries are often uninformative and lack detail for example ‘no change to care plan’, ‘care plan still okay’’. Care staff were knowledgeable about the cares needed for individuals and able to demonstrate verbally, the care provided. The records showed good assessments of health care needs, and in discussions with the Manager and a number of residents the healthcare services used and how they are accessed were well described. Regular contact with GP’s, optician, chiropodist, and other professionals is well documented and shows that service users health care needs are fully met. Hawksbury House DS0000007379.V262561.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, 13 &14. Residents are provided with a range of opportunities to participate in a variety of social activities and events to suit their expectations and preferences. Service users are encouraged and supported to lead lifestyles based on their preferences and choices. Links with families, friends and the community are maintained and service users are supported by staff in doing this. EVIDENCE: The majority of residents spoke of the recent events, activities and entertainments organised for Christmas and of the opportunities they had to go shopping, and to forthcoming outings planned. Some spoke of the very good Christmas arrangements and Christmas meals they had. One resident said that the menu that had been prepared by the catering staff was “excellent and better than you could get any where”. This resident took the time to show the attractive and well-presented menu cards that had been placed on the tables and felt that this showed a very considerate and respectful approach by the catering staff, in producing them for the residents living in the Home. A programme was displayed of the forthcoming events and entertainment and during the afternoon, an entertainer provided music, comedy and song to the residents, which they all enjoyed. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 12 Residents said they choose where their spend their time and what they do with it and this was observed to be the case during the day. All residents spoken with were consistent in their view that staff were very helpful and supportive. Staff were seen to ask residents what they wished to do, where they wished to go where assistance was required, and of generally offering choices to them on various matters throughout the day. Residents were also observed coming and going as they chose and were able, and generally doing things to suit their individual preferences. The homes’ philosophy encourages residents’ friends and families to visit and maintain links with them in the home according to their wishes. Evidence was seen of this during the day and visitors came at different times and spent time with residents as and where they chose to, and conversations with residents and a visiting relative confirmed this to be normal practice. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. A suitable complaints procedure is in place and is made known to residents and relatives. Residents and relatives feel confident that complaints would be listened to and acted upon appropriately EVIDENCE: A procedure is available and is displayed in the home, which gives clear information about how, and who complaints can be made to. The records showed that complaints are documented appropriately and include outcomes with signatures obtained to confirm the complainant’s satisfaction of the outcome. Within the complaints records file were numerous letter and cards of compliments from relatives to the Manager and staff for the care and support given to service users and relatives, both during their stay in the Home and following deaths. Residents and visiting relatives who were asked said that they were aware of how and who to make complaints to, and felt confident to do so if it was necessary, and that the Manager was very helpful. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 14 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): 20, 22 & 24. Residents live in a well maintained and clean Home where the facilities are appropriate and comfortable. Bedrooms are safe and comfortable and contain items of residents’ personal possessions. EVIDENCE: A choice of lounge and dining areas are available for residents and are all comfortable and tastefully decorated and furnished. The home has an adequate level of adaptations and equipment and provides a passenger lift to and from the first floor and stairs at each end of the building. Grab rails are available in corridors and toilets to assist service users to maintain their independence. Specialist equipment such as bath hoists and mobile hoists are available to assist residents. In one toilet/shower room the shower is rarely used and the Manager was advised that the water from the shower should be run for approximately 4-5 minutes weekly, with a record kept to confirm this, in order to prevent stagnation and bacteria build in the pipe-work and tubing connections. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 15 An emergency call system is available and accessible in all areas of the home used by residents, including individual bedrooms. Residents are encouraged to bring into the home personal items and furniture of their own. A number of rooms were viewed to confirm this as they were personalised to suit individuals. All were clean, odour free and generally well maintained. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 16 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): 27. Staff are provided in sufficient numbers and skill mix, and receive good levels of appropriate training to enable them to meet residents’ needs. EVIDENCE: Discussion with the Manager and inspection of the staffing rotas confirmed that appropriate levels of staff are provided in the Home over the twenty-four hour period. Staffing levels are adjusted at times where increased needs are identified. Some staff have the experience or have received the training to enable them to carry out various role functions such as catering, laundry, domestic or care work, but such roles by individuals are specifically identified on the staffing rotas. The residents and a visiting relative spoke very highly of the care and commitment shown by staff in their work and of the support given to them by staff. Some comments received were,” the staff are always there when you need them” and “ they’re all so kind and helpful”. One relative said, “mother settled here very quickly and she’s well looked after”. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 17 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, 33, 35, 36 & 38. The Registered Manager is also one of the Registered Providers and has the appropriate qualifications, competence and experience to run the home to meet its stated purpose and aims. Some systems are in place to monitor the quality of the service provided to ensure the Home is run in the best interests of the residents. Appropriate systems are in place to safeguard service user’s personal allowances. Staff receive appropriate supervision, which assists in promoting and safeguarding the best interests of service users. The health and welfare of residents is promoted and protected but some safety practices were not maintained on this occasion. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 18 EVIDENCE: The Manager has a Registered General Nurse qualification and many years experience in care work and management. She has the Registered Managers Award and NVQ Level 4 qualification. The Manager attends training provided for her staff and also any specialist training to enable her to remain current in her knowledge appropriate to the service and care provided to residents. Staff, residents and relatives spoke of her approachable and supportive manner. Some quality assurance methods for monitoring the service are used and include service user questionnaires, which, where residents require help to complete, an independent person assists with in order to protect any comments of sensitivity residents may wish to make, and confidential staff and visitor questionnaires. Residents and staff meetings are held and records are kept of the items discussed. The residents meetings indicate a genuine attempt by the staff to involve the residents in the running of the home. Minutes of the previous meetings displayed in the Home provide evidence of this. Six monthly care reviews are carried out, also audits of medications and housekeeping matters. From the results and feedback of these measures an annual report and action plan is developed to maintain and improve the service where necessary. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 19 Residents are encouraged to handle their own financial affairs for as long as they are able and wish to do so. The Manager is not appointee for any residents and where residents are unable, relatives handle their affairs. Fees are paid to the Home by bank standing orders or direct debit. Personal allowances for residents are handed to the Home by relatives or other representatives and receipts are given. Residents’ personal allowance monies are held in individual containers and individual records are kept, with separate pages for each resident, and with supporting receipts and signatures. Inspection of a sample of residents’ personal allowance accounts was carried out. Clear, accurate records are maintained and a check of individuals’ monies held in the Home, against their records were found to be accurate. A policy is available about the financial matters of residents and the Manager was advised to expand this to incorporate the all the procedural steps taken to safeguard residents’ financial affairs. Residents monies held in the Home are held in a secure area and limited access by staff to residents’ monies is available. The Manager described the health and safety training provided for all staff and the general fire and health and safety and practices and procedures carried out by staff during this visit were satisfactory with one exception. Residents’ hairdressing procedures were taking place during the inspection and the hairdressing room on the first floor could not accommodate the numbers of residents present at one time. The two wall mounted hairdryer hoods were not functioning and the practice has developed of using the electric socket in the residents’ room, opposite the hairdressing room. A freestanding hairdryer and chair were placed in the room doorway. Another resident in a wheelchair had a hairdryer hood in place with the electrical dryer positioned on a chair behind her, in the corridor. These practices compromise fire safety by causing obstruction in the corridor and to the fire exit, present a potentially unsafe hazard by having the electrical dryer on a potentially flammable chair. The privacy and confidentiality and security of the resident whose room is used to accommodate the freestanding hairdryer, although she was said to have agreed to this, is also compromised. These issues were discussed with the Manager who agreed to review these practices and take appropriate actions to address them. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 20 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 3 3 X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X X 3 X 3 X 3 X X STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? NO 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 OP38 Regulation 23(4) Requirement The Manager must ensure that all fire and health and safety practices are maintained at all times in relation to the hairdressing facilities. Timescale for action 05/01/06 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. Refer to Standard OP35 Good Practice Recommendations The Manager should expand the financial policy to include all steps of the procedures taken when dealing with residents’ finances. Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection South of Tyne Area Office Baltic House Port of Tyne Tyne Dock South Shields NE34 9PT 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. Extracts may not be used or reproduced without the express permission of CSCI Hawksbury House DS0000007379.V262561.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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