Inspection on 12/09/07 for Hawthorn Drive 218

This inspection was carried out on 12th September 2007.

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

Hawthorn Drive 218 23/06/09

Hawthorn Drive 218 24/05/06

Hawthorn Drive 218 04/01/06

Hawthorn Drive 218 01/06/05

Hawthorn Drive 218 18/01/05

Hawthorn Drive 218 07/07/04

Similar services:

Claremont House

Oak Ridge

Sun Court Nursing Home

Ashville House

Bilney Hall

Hill Barn

Mabbs Hall Nursing Home

Henrietta House

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

CARE HOMES FOR OLDER PEOPLE Hawthorn Drive 218 218 Hawthorn Drive Ipswich Suffolk IP2 0RG Lead Inspector Deborah Kerr Key Unannounced Inspection 12th September 2007 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 Hawthorn Drive 218 DS0000037656.V351183.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. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorn Drive 218 Address 218 Hawthorn Drive Ipswich Suffolk IP2 0RG 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) 01473 685772 01473 686490 beverley.gilbert@suffolkcc.socserv.gov.uk (Beverley with e) Suffolk County Council Mrs Beverly Ann Gilbert Care Home 29 Category(ies) of Dementia - over 65 years of age (19), Old age, registration, with number not falling within any other category (10) of places Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2006 Brief Description of the Service: 218 Hawthorn Drive is a purpose built residential care home designed by the local authority and has provided care and accommodation to older people since 1966. In 1995 the home was extensively refurbished to improve environmental standards and provide accommodation to twenty-nine residents. The home is located in the centre of the Chantry Housing Estate to the south of the town of Ipswich. There is a regular bus service into Ipswich town centre and a good range of facilities located just across the road including the post office, bank, newsagents, public house and health centre. 218 Hawthorn Drive is registered to provide accommodation for twenty-nine older people, nineteen of whom have a diagnosis of dementia. The home also offers a respite care service and provides a fifteen-place day centre, which has its own budget, access, staffing and accommodation. The home has a Statement of Purpose and a ‘Residents Information Pack’ providing information for prospective people to use the service, which is available on request. The information pack contains a summary of the statement of purpose and the current charge for a Suffolk County Council home. Each person’s fees are calculated by their level of income and capital. Further details about charges are available in a booklet called’ A Guide to Charges for Care in Suffolk’. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over eight and a half hours. This was a key inspection, which focused on the core standards relating to older people. The report has been written using accumulated evidence gathered prior to and during the inspection, including information obtained from the Annual Quality Assurance Assessment (AQAA), issued by the Commission for Social Care Inspection (CSCI) and resident’s and relatives ‘Have your say’ comment cards. Additionally a number of records were inspected, relating to people using the service, staff, training, medication, health and safety and a range of policies and procedures. A tour of the home was made and time was spent talking with six staff and three people living in the home. The Registered Manager was present throughout the inspection and fully contributed to the inspection process. ‘Experts by Experience’ are an important part of the inspection team and help inspectors get a picture of what it is like to live in or use a social care services. The term ‘experts by experience’ is used to describe people whose knowledge about social care services comes directly from using them. Alison Shaw, Expert by Experience joined the inspector on this site visit. Alison’s comments and observations are added to this report and can be identified in bold text. What the service does well: My visit was a very pleasant one. My impression of the Care Home is that it is clean, bright, airy, and fresh. The day of the inspection was a beautiful sunny day and several of the windows and doors were open, making visits to the garden very tempting and encouraging. Everybody in the home, both staff and residents, appeared to be happy and smiling, giving a feeling of well being. My impression was of a well organised team of contented workers, keen to do their tasks to the best of their ability. Hawthorne Drive is nicely decorated throughout offering a good standard of accommodation. Care plans clearly reflect the individual’s health and well being and provide a plan of care that is responsive to the varied and individual needs and preferences of the people who use this service. The home’s compliments file contained cards from previous short stay customers, one commented “ I would like to thank you all for your kindness you gave me whilst I was with you, you are all first class, thank you”. The home continues to offer people a well balanced and nutritious diet. People spoken with confirmed they are able to choose from an extensive menu of home cooked food. They described the food as “very nice” and “food is generally very good, I get asked every day what I want to eat”. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5, 6, People who use the service experience excellent quality outcomes in this area. People who may use this service are provided with information they need to make an informed choice about where they live and can expect to have a detailed assessment undertaken to ensure the home can meet their individual needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A detailed statement of purpose, sets out the aims and objectives, services and facilites provided at Hawthorne Drive. Additionally, a ‘Residents Information Pack’ provides relevant information about the home, which includes a copy of a Suffolk County Council brochure and the complaints procedure entitled “Having your Say”. Information provided in the AQAA and verified at inspection confirmed that significant time and effort is spent in making the addmission of a new resident into the home as easy and personal as possible. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 9 This is particulary evident with the short term care placements. The home has developed a pre addmisson pack containing all the documents required to ensure the process is well managed. All asssessments are carried out by a qualified person before the admission process commences. A member of the senior team visits the person either in their home or at hospital. The preadmission procedure ensures the home can meet the identified needs of the prospective individual to include their cultural and social preferences. A short term care pre stay visit is arranged to ensure that all relevant information essential to their care is fully discussed. An individual who had moved into Hawthorne Drive on a permanent basis, spoke of being involved in a series of meetings with people from the home and their family prior to moving in, to ensure that Hawthorne Drive was a suitable placement, and commented “it is a wonderful home, I really cannot complain”. Individually and collectively staff have the skills and experience to meet the needs of the people living in the home. New staff are required to complete induction training, which covers the specific needs of the people they are expected to support. Additionally, staff have attended training to understand and manage incidents of challenging behaviour, optical awareness and most recently dementia awareness. The home is constantly reviewing and updating how they meet the needs of the people using the service. Twice yearly the home is visited by people trained by the University of Bradford to evaluate the quality of person centred care delivered to people with dementia living in the home. The staff recruitment process identifies the skills and experience of potential employees. Both processes add to the quality of services and care the home is able to offer. People’s files contained a written contract setting out the terms and conditions of residence, including a trial period and information about charges. People using the short-term care respite facility are required to sign a customer contract with the home. A selection of compliment cards thanked the home for the care and attention of people that had resided in the home or used the short-term care facilities. One commented “I would like to thank you all for your kindness you gave me whilst I was with you, you are all first class, thank you”. The home does not provide intermediate care; subsequently this standard is not applicable. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10, 11, People who use the service experience good quality outcomes in this area. The health and personal care that people receive is responsive to their individual needs and preferences, however, to ensure the safety of people whom have their medication administered by staff, the procedure for recording or refusal of medication needs to improve. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home is divided into three units, one person was case tracked from each unit as part the inspection. Information provided in the AQAA and verified at inspection confirmed that care plans are started from the needs assessment prior to admission; they evolve as the needs of the person are established. At all times the home follows person centred care planning approach. The care plans are a live document used by the staff team daily and change accordingly. Key workers consult with residents on all aspects of their care, which is then reflected in the care plan. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 11 Care plan’s contained a current photograph of the person together with their personal details. The plans are well organised and provide detailed information covering all aspects of the individual’s health, personal and social care needs. They also identify the level of support required by staff to support the individual to be as self-managing as possible. The age range of the residents I spoke with was from mid-70 to 100. The residents were keen to attend to themselves as much as possible and are fairly independent but assistance, if needed always seemed to be at hand. The daily recording notes are well documented and clearly reflect the care and general state of well being of the individual and where medical intervention is required. Regular visits were documented showing that people are supported to access their general practitioner (GP) and other local health services relevant to them. Professionals visit in the privacy of the person’s room respecting their right of dignity and privacy. Relevant health charts and assessments are in place, relating to moving and handling, pressure care and tissue viability, nutrition and continence management. Generally these are being reviewed to monitor and reflect the individual’s current and changing needs and where intervention is required. During the visit I spoke to two medical staff calling in to administer insulin to one of the residents. They explained that they would deal with any medical problem following a request from the doctor’s surgery. The home has detailed policies and procedures in place for the receipt, storing, administering and retuning medication, including controlled drugs. Staff spoken with and training records confirmed that staff who are responsible for administering medication have received up to date medication training. A senior member of staff was observed administering the lunchtime medication. The Monitored Dosage System (MDS) is used. Blister packs had a front sheet with the individual’s details. These include a photograph for identification purposes and important reminders to prompt staff to remember to sign the Medication Administration Record (MAR) and to use the codes to identify where medication is not administered. Generally, the process of administering medication is well managed. However, examination of the MAR charts identified a gap on one person’s chart, there was no signature to identify if their medication had been administered. The person’s gavsicon was also recorded as being out of stock since the 3rd September. The manager investigated these issues during the inspection and identified the resident had gone out before taking their medication. This should have been recorded on the reverse of the MAR chart. There had been a mix up with the pharmacy, which had delayed the issue of gavsicon. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 12 People living in the home have the option to self medicate. Care plans included risk assessments where individuals had requested and had been assessed as capable of administering their own medication. These are subject to periodic review to ensure the individual is taking their medication correctly. The care plan of an individual identified they had been refusing their medication on a regular basis. The home had sought advice through a multi disciplinary meeting, including the individual’s social worker, relative and psychologist, whom concluded that covert administration of their medication, in food was the best outcome for individual to ensure they received their prescribed medication. During the inspection, staff were observed treating people living in the home with respect and dignity. The interactions between the individuals and staff were observed to be friendly and appropriate. A tour of the home confirmed people are able to choose to have a private telephone in their own rooms to make personal calls or they can make use of a mobile phone box. Care plans did not have sufficient information relating to the end of life needs of people using the service. The AQAA states as part of the key worker role as much information about final wishes is gathered and documented. This information related to funeral arrangements. The end of life needs were discussed with the manager. Individuals’ care plans need to be updated to reflect their wishes, choices and decisions as their health deteriorates and have an established plan, which constantly monitors pain, distress and other symptoms. Information in the AQAA does recognise the importance of supporting people living in the home to spend their final days in familiar surroundings. There are facilities for friends and relatives to stay with the resident at this time. Hawthorn Drive 218 DS0000037656.V351183.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, 15, People who use the service experience good quality outcomes in this area. The home provides a good choice of wholesome and appealing food, however not all people living in the home have the opportunity to join in meaningful day time activities of their choice, according to their individual interests and capabilities. This judgement has been made using available evidence including a visit to this service. EVIDENCE: People using the service shared their experiences about what it is like for them living at the home. The majority of the residents had lived and worked in the area and it was interesting to talk about the various types of work they had been involved with. People spoken with confirmed that they are able to maintain links with their past. An individual had previously belonged to a choir and had been visited during the day by members of that choir. Another person spoke of their life membership of a local football league, they had been escorted to an evening at the club, where they had met up with old aquaintances. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 14 A hairdresser visits the home once a week and if requested, a chiropodist will also visit. People confirmed that visitors are welcome at any time and entries in the visitor’s book confirmed that friends, relatives and family visit on a regular basis. Local religious groups also visit the home. One individual confirmed “I am supported to continue to practice my faith, I have a weekly visit from the local parish”. Other people commented, “ I get on well with the staff and the food is very nice” and “I am happy here, I have been here for four years and have no serious complaints”. During my visit today, I met with residents in both Cedar and Larch units, but did not visit residents on the first floor unit. Each unit has their own kitchen/dining room and there is a “Coffee Shop” where coffee or tea can be served at any time. During my visit there were no obvious activities but the residents seemed content with either sitting in the garden, in the lounge area or in their own rooms. I understood that a variety of activities are organised regularly Monday to Friday. Information provided in the AQQA identified that residents are encouraged to exercise their choice in leisure, meals and routines of daily living. We have a team of Life and Leisure staff, dedicated to providing leisure and social activities. Each of the units provides people with a choice of how they spend their time, such as one to one, group sessions, outings, particular requests from individuals and we bring in entertainment from other sources. Staff raise funds to accommodate this. Feedback from a relative’s questionnaire stated, “we believe our relative is happy at Hawthorne Drive, however they have severe dementia and as a consequence has limited input to choice and control over their life. Other comments, stated “we are unsure of the extent of activities for people with dementia, our relative appears to spend most of their time in their room” and another “we are concerned about limited activities, we witness very little activities taking place, when we visit”. Each unit has an activities folder with scheduled activities for the week and a record of activities attended by each person. However, the records showed little evidence of activities taking place. This was discussed with manager, who confirmed activities do occur, but believed this to be an issue of staff not recording when they engage in an activity with an individual. Staff spoken with also confirmed that activities do take place, however, resident’s willingness to join in and staffing levels influences if these actually happen. A survey conducted in May 2007 asked six people living in the home their views of a range of services provided at Hawthorne Drive. Comments relating to activities stated that “I am happy with what goes on” and “I am happy with activities, but prefer to watch my television” and “I do not wish to take part in activities” and “I do not wish to go on outings, I like to sit quietly” and “at my age I think there is enough activities”. Social activity means different things to Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 15 different people, whilst it is recognised that not all people wish to participate in scheduled activities, each individual must be offered meaningful day time activities of their choice, according to individual interests and capabilities. The survey also asked for feedback regarding the catering arrangements. Comments included” I am very satisfied with food and find the catering staff very helpful and approachable, the food always looks nice and I do discuss the food with the team” and “I like the food here, I always get what I ask for”. People spoken with during the inspection confirmed that the food is generally good with plenty of choice and stated “we are asked every morning what we want to eat, there is a good team of chefs”. I had lunch with one group and on a table for five people; there were four different main courses. All the residents were enthusiastic about the selection of food available. There was also a selection of five different sweet dishes with the option of ice cream added. The table was nicely set, the vegetables served in individual dishes for each diner, a selection of soft drinks available, making the whole thing a very pleasant experience. There is also a choice from the breakfast menu and any special diets are catered for. Information taken from the AQQA, confirmed that a member of the catering team visits each resident individually each day to discuss their daily menu. Individual diets and tastes are met daily. Meals are taken in the preferred area by the person ie. breakfast in bed, lunch in coffee shop or chosen by the group ie. tea in the garden. There are no restrictions around time or place at mealtimes. Hot/cold drinks and snacks are available on each unit throughout the day and night and those able to help themselves are encouraged to do so. The menu is provided in a written format and photographs to enable people with special needs to make individual choices. The menu for the day of the inspection offered people a choice of the special main choice, which was homemade chicken pie alternatively they could choose from a range of other foods, such as omelette with filling of their choice, fish, meat or cheese salads, jacket potato, fish, soup or ploughman’s. Mealtimes are flexible and people were observed taking as much time as they required to enjoy and finish their meal in a relaxed and comfortable setting. A meal record sheet is kept to monitor peoples diet and intake of food. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 16 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, 17, 18, People who use the service experience good quality outcomes in this area. Residents and their relatives can expect to have their concerns or complaints listened and responded to, have their legal rights protected and can expect to be protected by the home’s adult protection procedures. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA and verified at the inspection confirmed that the home complies with the Suffolk County Council complaints procedure, dealing with compliments, comments and complaints. All people using the service are provided with a copy of the leaflet in the information pack. This information is available in other formats from Suffolk County Council including Braille and audiotape for those registered blind or with visual impairment. All actions and events are appropriately recorded in the complaints logbook. The home deals with issues in the first instance thus avoiding the need to action the complaints procedure. This was confirmed when talking with people living in the home, who confirmed they would raise any concerns with the manager as they occurred. A residents comment card, also stated, “ I will discuss problems with the team leaders or manager rather than follow the “complaints procedures”. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 17 The complaints log was seen; the last complaint entry was made in August 2003. The complaint had been investigated, and the findings fed back to the complainant who was satisfied with the outcome. The AQAA reflects that people using the service are supported to excercise their right to vote. This was evidenced at the previous inspection of May 2006; people that choose too are escorted to the local polling station to vote, which is held in a nearby church. Others are able to vote by post. The Vulnerable Adults Protection Committee (PAVC) was disbanded in February this year and the Adult Safeguarding Board (ASB) created in its place. The procedure for reporting allegations of abuse guides staff to refer all allegations of abuse to Social Services, Customer First Team. The AQAA states that the home has a thorough recruitment policy in place, which ensures all appropriate checks are obtained prior to new staff starting employment. Staff personnel files seen at the time of the inspection, confirmed that all newly employed staff are subject to Criminal Records Bureau (CRB) and Protection Of Vulnerable Adults (POVA) checks. Additionally, all staff completes POVA training. The training records confirmed that all staff had attended training to recognise abuse in the home. Staff spoken with demonstrated a good understanding of what constituted as abusive practice and would have no problem reporting an incident or an individual if they had any concerns about their conduct. The AQAA reflects that residents are encouraged to manage their financial affairs where possible, however full support is offered where it is needed. The process was discussed with the manager. The home manages the accounts for people for whom they receive contributions and their personal allowance. All monies are dealt with through the Suffolk County Council bank; each person has their own separate account. The administrator oversees each person’s account. A database provides an audit trail of expenditure where money is withdrawn and a record of their personal allowance is paid in. Where an individuals care plan identified their behaviour could be challenging to others living in the home, support had been obtained from the Suffolk Specialist Mental Health Services to help staff to understand triggers to the behaviour and how to deal with the individual’s behaviour appropriately. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 18 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, 20, 21, 22, 24, 25, 26, People who use the service experience excellent quality outcomes in this area. The physical design and layout of the home enables the people who use his service to live in a safe well-maintained and comfortable environment. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The home has previously been found to offer accommodation to a very high standard, therefore a brief tour of the environment was made. Hawthorne Drive continues to offer people a home that is nicely decorated throughout, with fresh bright colours. Plants, papers and magazines and personal items belonging to residents were observed around the home, creating a comfortable and homely atmosphere. Furnishings and lighting throughout the home are domestic in character and are suitable for their purpose. The home is divided in to three units; two of which are on the ground floor. Cedar is designated for short-term care customers, whereas Larch provides permanent residential accommodation. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 19 Willow, is on the first floor, accessible via passenger lift and two staircases. The unit is divided into two, called Herbs and Flowers, providing care to people with dementia. The doors at the top of each staircase are kept shut to reduce the risk of people wandering and injuring themselves by falling down the stairs. The doors are fitted with a release button on the inside, if a resident opens the door; an alarm sounds alerting staff to check who has opened the door. This ensures that people residing on the first floor are not restricted to other parts of their home. The gardens are landscaped and well maintained providing a nice environment for residents to walk and sit in the nicer weather. Ramps on the ground floor provide a means of exit for wheelchair users. The garden is lovely. Lots of seating, tables set in various parts of the garden, some in the sunshine and some in the shade. There are very pleasant water features and many shrubs and flowers. A fence surrounds the garden providing security. Additionally, staff and visitors only have access to the car park and garden with the use of a swipe card. All visitors have to report to reception. Information provided in the AQAA and verified at the inspection confirmed that the home provides a comfortable and safe home for the people to live in and for the staff to work in. Hawthorne Drive is suited for the purpose of providing reisdential care, it is divided into unit living to ensure a homely enviroment is achieved. Each unit has it’s own lounge, bathroom, kichen/dining rooms and all single bedrooms, with the exception of two bedrooms, they all have ensuite facilites. All the bedrooms conform to the required standard size. Each unit has a separate sluice room. Health and Hygiene are a priorty which is reflected in the clean, pleasant and hygenic conditions of the home. Additionally, all staff have completed a Vocational Recognition Qualification (NRQ) level 2, for the control of infection and contamination. Inspection of the laundry facilities confirmed the home has good procedures in place to prevent and control the spread of infection. The laundry was clean and tidy with appropriate equipment to launder clothing and bedding. The washing machine has a sluice facility for dealing with soiled linen. Appropriate handwashing facilities of liquid soap and paper towels are situated in all bathrooms and toilets where staff may be required to provide assistance with personal care. Random testing of water temperatures reflected that the water supply is within the recommended 43 degrees centigrade, which minimises the risk of people living in the home scolding themselves when taking a bath or shower. People’s bedrooms were quite roomy, not cluttered and had spacious en-suite bathrooms. All paintwork, upholstery, carpets, flooring were all in really good condition. Nothing appeared tired or grubby. People’s rooms are personalised to meet their needs and tastes. People moving into the home are able to bring small items of furniture as well as other personal items such as ornaments, pictures and photographs. Lockable storage space is provided for small items of value. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 20 Each person is offered a key to their bedroom door, however staff have an override key in case of emergencies. Feedback from the residents survey about their bedrooms and communal areas included comments, such as “my room is pleasant, I am pleased with everything” and “I am very pleased with my blue room and the size” and “ I am very happy with the home, it is homely and friendly and always tidy”. All corridors, bathrooms and toilets are fitted with grab rails, these are positioned to provide additional support for people and to help them maintain their independence. There are adequate number of communal assisted bathrooms, showers and toilet facilities to meet people’s needs. Appropriate aids for safe moving and handling were sited around the building and evidence was seen that people are provided with aids and equipment for the prevention of pressure areas, where required. Hawthorn Drive 218 DS0000037656.V351183.R01.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, People who use the service experience good quality outcomes in this area. The home has an established staff team, available in sufficient numbers who have the skills and experince to meet the specific needs of the people living in the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five staff are split across the units each shift, supported by a team leader. Early shifts are between 7-3pm and late shifts are between 2-10pm. Cedar unit has eight residents with one member of staff, Larch has five residents with one member of staff and Willow has three staff to sixteen residents. However, staff will work across all the units to help each other out when required. There is one team leader and two waking night staff on duty through the night. In addition to the care staff there are a team of domestic staff, catering staff and a maintenance person. I spoke to several members of staff. All were more than willing to spend time with me, answer anything I asked; they were very pleasant and extremely caring with the residents. People spoken with were complimentary about the staff and were confident that they met their needs. Comments in the residents survey’s conducted by the home in May 2007 included “We have got good staff here, they are always approachable and polite” and “I am satisfied with the staff, nothing bad to Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 22 say”. Residents and relatives comment cards confirmed this, verifying that staff are very kind and helpful. Information provided in the AQAA identified staffing numbers are appropriate to the size of the home and the needs of the residents. Rosters allow for planned staff absense such as annual leave or training and for unplanned absenses such as sickness. The standard of care is maintained during the night by a night team leader and two carers, all three are waking night staff. The home has robust recruitment process with a job description and person specification for every job role. Equal opportunities is promoted. Carers are registered with Skills for Care and receive a full induction. New staff complete induction and shadow shifts to ensure they fully understand what is required and to ensure the people living in the home receive a safe service. Each new member of staff is issued with ‘A Staff Guide’ which covers all aspects of employment, this is given on their first shift alongside all core employment information. Evidence to substantiate this was seen on staff files examined during the inspection. A requirement was made at the previous inspection for Criminal Record Bureau checks (CRB) and Protection Of Vulnerable Adults (POVA) checks to be undertaken prior to a new employee commenced employment. Examination of staff files confirmed that the home now operates a robust recruitment process, which adheres to the Suffolk County Council policy. Staff files seen were well organised and contained all the relevant documents and recruitment checks, including a CRB and POVA check. Records confirmed that staff are provided with the training they need to gain the knowledge and skills to perform their work role. This includes all areas of mandatory training, for example, moving and handling, recognise and respond to abuse and neglect, emergency first aid, infection control and fire safety. Training more specific to the individual needs of the people using the service has included dementia awareness, optical awareness, and unisafe physical deescalation techniques. Staff spoken with confirmed they receive good training, which is relevant to their role and which helps them to understand and meet the needs of the people using the service. Figures taken form the AQAA reflect the home employs 37 care staff of which 29 are permanent staff, with 8 bank staff. There is a continous rolling programme of National Vocational Qualification (NVQ) for both carers and team leaders. All staff are over 18 years of age. 22 of the permanent staff have achieved NVQ Level 2 and above, with 2 staff working towards completion. 6, bank staff have completed NVQ 2, with 1 working to completion. These figures reflect that Hawthorne Drive has exceeded the National Minimum Standard (NMS) target of 50 of care staff to hold a recognised qualification. Hawthorn Drive 218 DS0000037656.V351183.R01.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, 32, 33, 35, 36, 38, People who use the service experience Excellent quality outcomes in this area. People using this service benefit from the leadership and management approach of the home, which is based on openness and respect and tested by an effective quality monitoring system. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Information provided in the AQAA and verified at the inspection confirmed the Registered Manager is qualified and experienced in the running of a home. They have a proven track record of delivering a good quality service. Although the manager is in day to day control there are clear lines of accountability and delegation of duties within the whole staff group. All staff have the opportunity to share in the way the service delivery is planned and actioned. Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 24 Feedback obtained through discussion with people using the service and residents and relatives comment cards was positive. People find the manager approachable, friendly and supportive. There is a good continuity of staff who are very approachable and they have a good relationship with the residents. Comments included “Hawthorne Drive is very well run home, my relative has Alzheimer’s, they are well looked after, by the staff” and “staff have my relative’s best interests at heart” and “the manager is very good, they have selected a very good team of leaders and carers”. Two comment cards reflected people’s anxieties about the sale of the home to the private sector. This was discussed with the manager who advised that Suffolk County Council are currently looking at plans to maintain some control of the homes currently registered, but are looking to work together with other organisations in partnership. The manager confirmed there has been no further decisions made at this time and that people will be kept informed of decisions at residents and relatives meeting and through the County Councils Homes for Older People, newsletter. The home has regular residents meetings and relatives are encouraged to attend. These provide a forum for people using the service to raise any concerns or suggestions they may have. The home has good quality monitoring systems in place. The most recent surveys were conducted in December 2006 for relatives and friends and in May 2007 for people using the service. The outcomes of these surveys are positive and comments have been used throughout this report to reflect where people feel they have received a good service. Overall people felt that they were content with the service and can approach the manager or team leaders if they have any concerns. The AQAA states that all financial records are kept and comply with Suffolk County Councils Policys and Procedures. All Insurance cover is in place. Where they are able, people living in the home receive their weekly allowance, where they are not it is recorded and they are assissted in a dignified manner to manage their monetory needs. Clear records are kept of money spent on behalf of a person. The manager does not hold appointeship for any person living in the home. All information regarding a resident is available for them to access and is kept secure at all times. The AQAA identifies that all staff are supervised and trained appropriatly. Staff personnel records seen confirmed that a formal supervision process is in place. Records confirmed that work issues and performance, training and further development needs had been discussed. Records examined at the inspection and information provided in the AQAA confirmed the home takes steps to safeguard the health, safety and welfare of people living and working in the home. The most recent Gas and Electrical Safety Certificates, including Portable Appliances Testing (PAT) were seen and records showed that equipment is regularly checked and serviced. Additionally Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 25 the home has carried out a first aid risk assessment to ensure the home has the correct cover in place. All relevant documentation is in place to comply with the Control Of Substances Hazardous to Health (COSHH). The building complies with enviromental health standards and the local Fire service requirements. The Fire alarm system is serviced on a regular basis. A previous requirement was made for regular fire drills to be undertaken. The fire logbook confirmed that regular drills are now taking place and a record of the duration of the evacuation and outcomes of the drill are being recorded. Time was spent with the cook, who demonstrated a good understanding of the needs of the people living in the home, the importance of good food hygiene and health and safety. All meals are ‘home-cooked’ using mainly fresh ingredients. The food store seen confirmed that the home has a good range of quality food. These were being stored in accordance with food safety standards. Documentation was produced to show that the required temperature checks for fridges, freezers and food delivered to the home are being kept. Cooked food is taken from the main kitchen to the units in hot trolleys. The cook was advised they should keep a record of the temperature of food when cooked to ensure food is served at correct temperature. The AQAA states all staff handling food are required to undertake food hygiene training and refresher on an annual basis. Hawthorn Drive 218 DS0000037656.V351183.R01.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 3 3 4 4 4 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 2 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 4 4 3 X 4 3 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 4 3 X 3 3 X 3 Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 27 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 OP9 Regulation 13 (2) Requirement Medication Administration Records (MAR) must be completed whenever prescribed medication is administered to a person living in the home. This will ensure that people receive the correct levels of medication. The end of life needs of people living in the home need to be discussed. This will ensure that in these circumstances the individual and their relatives will be treated with dignity and respect and in accordance with their wishes. People living in the home must be consulted as part of the planning process to establish their interests and develop a programme of activities, which takes into account their preferences and ability. This will ensure that people are provided with a lifestyle that meets their expectations. Timescale for action 13/09/07 2. OP11 12 (3) 30/11/07 3. OP12 16 (2) (n) 30/10/07 Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 28 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hawthorn Drive 218 DS0000037656.V351183.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Colchester local office Fairfax House Causton Road Colchester Essex CO1 1RJ 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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