Inspection on 24/05/06 for Hawthorn Drive 218

This inspection was carried out on 24th May 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

Hawthorn Drive 218 23/06/09

Hawthorn Drive 218 12/09/07

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 Seddon Unannounced Inspection 24th May 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 Hawthorn Drive 218 DS0000037656.V293854.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.V293854.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 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.V293854.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 4th January 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 shops 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 homes kitchen also provides a community meals service on a daily basis. This service will be ceasing in June 2006. The home has a Statement of Purpose and a ‘Residents Information Pack’ providing information for prospective service users, 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, which is £387.60 per week. Further details about charges are available in a booklet called’ A guide to Charges for care in Suffolk’. Hawthorn Drive 218 DS0000037656.V293854.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 quarter 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. This included reviewing the progress of the requirements made at the last inspection in January 2006, and other documents required under the Care Homes Regulations 2001. Additionally a number of records held at the home were looked at including those relating to residents, staff, training, medication and policies and procedures. Time was spent talking with the senior team leader, five residents, a relative of a resident visiting and four staff. What the service does well: What has improved since the last inspection? A requirement was made at the last inspection for residents care plans to be reviewed regularly. Evidence was seen in the care plans that the home has taken steps to ensure that care plans are updated monthly. A tracking sheet has been implemented, reflecting the date and signature of the person updating the residents care plan. There is an additional record of the review, which reflects the resident’s involvement and any changes in their general heath and welfare. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 6 The Fire and Rescue service completed a fire safety audit of the home in April 2006. They made several recommendations, these were checked during the inspection and evidence was seen that the home had complied with the recommendations by installing automatic fire door closers and updating the home’s risk assessment. 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. Hawthorn Drive 218 DS0000037656.V293854.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.V293854.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6, The home has detailed service users to make a care. However, residents conditions between them EVIDENCE: Hawthorne Drive has a detailed statement of purpose and a ‘Residents Information Pack’. These are well presented and provide relevant information. The pack includes a Suffolk County Council brochure giving details about the home and the services they provide. The statement of purpose has a detailed admissions criteria, which provides prospective residents with information of the process they can expect to help them make a choice about moving to the home. Residents have the opportunity to visit for the day and attend a planning meeting with the manager and other key people to help them make a decision about whether or not the home are able to meet their needs. information and processes in place for prospective decision to move into the home and for short-term do not have a contract, which includes the terms and and the home. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 9 The care plans and personal files of three residents were inspected to track their care and the level of support they required. Evidence was seen in each of the files that a pre-admission needs assessment had been completed. Hawthorne Drive is registered for nineteen residents with a diagnosis of dementia. The home has created a separate unit on the first floor where the environment has been suitably adapted to provide the specialist care to meet the resident’s needs. There was no evidence on two of the resident’s files of the contract being completed. One was a short-term care placement and the other has been an established resident for some time. The third resident had only recently moved to the home, their contract was in their information pack, however it had not been completed. Contracts were discussed with the senior team leader. They explained that the resident that had recently moved to the home had their six week trial period review the day before the inspection and the contract should have been completed at that meeting. In the case of the resident that had been at the home for some time, the back page that they had signed was the only part of the contract that could be found. The home does not provide intermediate care, however does provide shortterm care for up to five people. The home has five designated rooms to accommodate these placements. Evidence was seen that the same process of admission applied to people using the short-term care as for permanent residents. Hawthorn Drive 218 DS0000037656.V293854.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11, Residents can expect to be treated with dignity and respect and supported to have access to healthcare services. Residents are protected by the home’s procedure for storing and administering medication. EVIDENCE: The care plans of three residents were sampled. Evidence was seen that each of the residents care plan’s reflected all aspects of their health, personal and social care needs. The care plans contained detailed assessments and associated records of residents needs with regards to mobility, continence, nutrition and tissue viability. Evidence was also seen that the home has support from other professionals to meet residents needs, for example a team of people have recently visited the home to carry out a dementia mapping exercise for all residents with a diagnosis of dementia. They have produced a report which reflects the level of support each individual requires for them to maintain a good quality of life. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 11 The home has regular input from the National Osteoporosis Society to make assessments of residents at risk of falls and develop strategies to reduce the risk of future incidents. Hawthorne Drive has close links with the health centre and district nurse team who offer support to the residents and advice to staff. In the case of one resident concern’s were raised with the general practitioner (GP) about some elements of their behaviour, which were challenging to others, the GP made a referral for the resident to be seen by a psychogeritricain. As a result of the assessment the resident is receiving additional daily support from the Mental Health Intermediate Care of Older People (MHICOP) team to help and support them to manage their behaviour. Evidence was also seen that residents’ have access to general health care appointments, such as the dentist, chiropodist and opticians. A requirement was made at the last inspection in January 2006 for the care plans to be reviewed on a regular basis. Evidence was seen that systems are now in place to update these on a monthly basis. The home has produced a tracking sheet, which is dated and signed by the key-worker. The key worker also produces a summary of the general health and well being of the resident during the last month, which demonstrates the resident’s involvement. The home has good systems in place for the receipt, storing, administering and retuning medication. These are in accordance with the home’s policies and procedures. Each resident has the option to self medicate or have staff administer their medication. A risk assessment process determines the residents’s suitability to manage their own medication and currently there is only one resident who administers their own medication. A team leader was observed administering the lunchtime medication. Medication is kept in resident’s rooms in a lockable cabinet. Senior staff hold the key and the Medication Administration Record (MAR) chart folder. Medication is dispensed in the resident’s room. MAR charts have a front sheet with the resident’s details and photograph for identification and preferences of how they wish to take their medication. For example, one resident prefers to have their medication with orange squash and to be woken, if asleep for their 9pm medication. All MAR charts seen were completed accurately and codes entered where residents had refused medication explaining the reasons why. The home has a separate locked cabinet for controlled drugs, which is located in the staff base. Only one resident is currently prescribed a controlled drug. The controlled drugs book was seen reflecting the resident’s name, dates, type of drug and the quantity held. The stock was checked and found to be accurate. Medication, which is unused or soiled is stored separately in a locked cupboard. These are returned to the pharmacist and a record kept in the returns book. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 12 A fridge was located in the same room, which contained insulin for one resident who self-administers. The temperature of the fridge was 4 degrees centigrade and within the recommended temperature, however, the record on the front of the fridge showed the last time the temperature was recorded was on the 28th April 2006. Medication brought into the home by people on short-term care is checked in and recorded on a MAR chart. The home discourage people bringing medicines, which have been decanted into dossette boxes, requesting medication in it’s original packaging and printed instructions by the pharmacist. Evidence was seen throughout the inspection that staff treat residents with respect. All new members of staff undertake training in respecting rights, choice, maintaining privacy and treating people with dignity as part of the induction process. Staff were observed speaking to residents showing patience, caring and understanding. Staff called residents by their preferred name and were respectful to their level of understanding, especially when speaking with residents who showed signs of confusion. Residents have access to a public telephone, which is on wheels so that it can be wheeled into their room to make private calls. One resident prefers to use their own mobile phone. The home has a policy and procedure for dying, death and bereavement, which gives guidelines to staff to ensure that residents rights are respected in the event of their death, sudden death and managing bereavement. Evidence was seen in residents care plans that these issues have been discussed and their decision ‘s respected if they do not wish to be resuscitated. Hawthorn Drive 218 DS0000037656.V293854.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15, People living in the home are supported to make decisions, choices and have control over their daily lives and a lifestyle that matches their expectations and preferences. EVIDENCE: Hawthorn Drive is situated in a residential area and has easy access to local amenities. The inspector spoke with a variety of residents and staff who confirmed that the home provides a range of activities to suit individual needs and abilities. A ‘Life and Leisure’ worker is employed 6 hours a day Monday through to Friday. Their time is divided between the residents to provide one to one or group activities. The life and leisure member of staff was observed bringing their dog into the home for the residents to befriend and spending one to one time with another resident walking in the garden. Daily routines are governed by the residents who are able to choose how they spend their time. Residents were observed taking their meals as they chose throughout the day either in the privacy of their room or in the dining room. A large communal area on the ground floor called the ‘coffee shop’ has recently been refurbished and provides coffee, tea and snacks throughout the day to residents, relatives and other visitors. This space is also used for social functions and special events. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 14 The home has a large garden to the rear of the building, completely surrounded by a fence. The gardens have been designed using sensory objects to provide stimulation for the residents. They have been landscaped incorporating tables and chairs at different intervals for residents to sit and enjoy the fragrant and colourful plants, bird tables and wind chimes that provide a soothing sound combined with a water feature. Residents and staff were observed using the garden at their leisure during the day. Each resident is provided with a key worker pack. These include an activity planner with a record of important dates for the individual to remember. There are different sections for example, people the resident wishes to remain in contact with, a family tree, likes and dislikes and details about the resident’s life from their perspective including information about “me and my ideal day”. Evidence was seen that these are completed providing an overview of the residents past, present experiences and future expectations. One resident’s key worker pack seen showed that they had lived in Ipswich all their life and that they enjoyed gardening, smoking, trips out and walks. Evidence was seen that the resident was supported to take part in activities that reflected their interests; they had been involved in planting vegetables including runner beans and tomatoes. They regularly go into Ipswich town centre and is able to enjoy smoking in a designated smoking room, with chairs provided, alternatively the resident was observed smoking outside in the garden by choice. the “life and leisure” member of staff had through discussion with a resident identified that they had been very interested in history. The member of staff had arranged and taken the resident by local transport to Christchurch Park and to a place of historical interest where they had enjoyed lunch. The home provides in house entertainment; one resident informed the inspector they had enjoyed a sing a long session recently, held in the coffee shop. Residents and staff were excited about the preparations in place for the summer fete to be held in July 2006. Residents are supported to maintain links with the community and exercise choice and control over their lives. The visitor’s book reflected that people regularly visit the home; a relative visiting during the inspection confirmed there are no restrictions on visiting hours. Residents are supported to manage their financial affairs and medication where possible. Risk assessments and systems are in place which monitor resident’s ability to self medicate, manage their expenditure and to ensure they receive their personal allowances. During a tour of the environment, the inspector spent time talking with the cook and observed the main meal of the day being prepared. The cook showed the inspector a menu folder, which contained a range of alternatives to the meal on offer, including ploughman’s, beef burgers, sausages, fish, jacket potatoes, omelette, soup and salads. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 15 The menus contained photographs, so that residents with special needs could identify meals and be able to make individual choices. The main meal was sausage and onions with gravy, mash and broad beans followed by homemade plum pie and custard. Residents were observed eating their midday meal. Evidence was seen that residents had chosen alternative meals to the main menu choice. One resident told the inspector they had had an omelette and others were observed eating rice pudding instead of the plum tart. All food is home cooked and made using fresh produce, which looked, appetising and appealing. Residents spoken with commented on the quality of the food, telling the inspector “food is lovely” and food is very nice”. Mealtimes were not rushed and residents were given time to enjoy their meal and the social occasion with other residents. The cook had raised concerns that some residents were not eating a varied diet and were requesting the same foods on a regular basis. A study of the nutrition records to see the individual habits of each resident was conducted and as part of the quality assurance monitoring process residents were consulted about food being offered. As a result additional choices have been introduced to the menu. Residents are consulted daily about their preference for meals and drinks. Hawthorne Drive provides accommodation for a separate day care service, which is funded by social services operating on its own budget and staff team. However, if there is an activity taking place residents from the home can join in. Monday and Friday’s activities are designed for day care residents with special needs. Resident from Willow unit are encouraged to join in these activities. Hawthorn Drive 218 DS0000037656.V293854.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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18, 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. EVIDENCE: Suffolk County Council have produced a leaflet for dealing with compliments, comments and complaints. Evidence was seen that all residents are provided with a copy of the leaflet in the information pack. This was confirmed when talking with a resident and their relative. A selection of compliments were seen between June 2005 and May 2006, which included compliments form relatives and people who have used the service for short stay care. Comments included, “Thanks for looking after my relative” and “big thank you for making me welcome”. There were many compliments about the facilities and décor of the home and the kindness of the staff. There have been no complaints received by the home since August 2003. The complaints log was seen and reflecting the last complaint entry of the 20th August 2003. The complaint had been investigated, and the findings fed back to the complainant who was satisfied with the outcome. Staff spoken with confirmed that resident’s rights are respected. Residents are supported to take part in the political process. Those that choose are escorted to the local polling station to vote, which is held in a nearby church. Others are able to vote by post. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 17 The process for reporting allegations of abuse was discussed with two staff. They were clear that they would immediately inform the home’s manager and the locality manager. They were aware of the procedure to inform the Customer first team in line with the Suffolk Vulnerable Adult Protection Committee (VAPC). Hawthorn Drive 218 DS0000037656.V293854.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26, Hawthorne Drive offers residents the opportunity to live in small sociable units providing a welcoming, friendly and comfortable atmosphere. The home is well maintained, safe, clean and hygienic. EVIDENCE: A tour of the environment was made. The home is nicely decorated throughout with fresh bright colours creating a comfortable and homely atmosphere. The environment was found to be clean and tidy and had no unpleasant odours. The home is split into three different units; each has a name. Cedar and Larch are on the ground floor with Willow on the first floor. Willow is divided in to two areas called Herbs and Flowers providing accommodation for sixteen residents with a diagnosis of dementia. Access to the first floor is by passenger lift and two staircases. The doors at the top of each staircase are kept shut to reduce the risk of residents wandering and injuring themselves falling downstairs. The doors are operated by touch sensor pads situated under the floor on the approach to the doors or by a swipe card. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 19 Residents are not restricted to access other parts of the home, the doors are fitted with a release button on the inside, which when released alerts the staff. Each of the units has their own dining room, lounge and small kitchenette for making tea, coffee and light snacks. Residents were observed making use of all these communal spaces which have views over the garden. All bedrooms are single occupancy and have en-suite toilet facilities. Resident’s rooms seen were clean and tidy and personalised to meet their needs and tastes. Evidence was seen that residents 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. Residents are offered a key to their bedroom door, however staff have an override key in case of emergencies. 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 from the dining room and fire exit into the gardens. A fence surrounds the garden; 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. The majority of the residents living at the home are mobile and can move around independently. All corridors, bathrooms and toilets had grab rails positioned to provide additional support for residents to help them maintain their independence. There are adequate number of communal assisted bathrooms, showers and toilet facilities to meet the needs of the residents. The senior team leader demonstrated that bathroom doors open both ways in case of an emergency. Evidence was seen that the home provides equipment to meet the needs of the residents for example a high low bed has recently been installed for one resident whose health needs have deteriorated. During the inspection of the building the senior team leader tested the opening of a fire door and raising the alarm, which demonstrated that the fire alarm system was functioning properly. The home has recently had an inspection by the fire and rescue service who made several recommendations. Evidence was seen that the home has complied with these recommendations by installing automatic fire closures on several doors. The fire and rescue officer had raised concerns about vertical blinds, which had been fitted across a fire exit at the end of the corridor in Larch unit. The home has amended the risk assessment and put up notices next to the exit of the actions staff must take to operate the vertical blinds in an emergency. A bedroom door widened to accommodate a resident has been made safe in line with the fire and rescue recommendations, however the glass window above the door was covered with a black plastic bag and cardboard to shut out the light, whereas curtain or blind would be more suitable and in keeping with the rest of the décor of the home. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 20 The maintenance person tests and monitors the water temperatures. Evidence was seen in the contractor’s logbook that they had requested a visit to adjust the water temperature for a wash hand basin in the kitchen on Willow. The entry in the logbook reflected that the water was reading 60º degrees centigrade, which exceeded the safe recommended temperature. The contractor had reset the thermostat at the correct temperature of 43º degrees centigrade. The home has good procedures in place to prevent and control the spread of infection. The home has several laundry facilities with each of the units having a laundry. There is also a main laundry room on the ground floor that has a washing machine with a sluice cycle. The home uses red dissolvable bags for soiled laundry and these are taken and put directly into the machine for sluicing. Staff have access to hand washing facilities with liquid soap and paper hand towel dispensers situated in every bathroom and toilet. Thirty members of staff are currently undertaking a Vocational Recognition Qualification (NRQ) level 2 in certificate for the control of infection and contamination. The senior team leader commented that to complete the workbooks and assignments staff have to revisit the home’s policies and procedures. This has raised their awareness of infection control measures required in the home. The maintenance person identified that staff were disposing of used gloves in normal waste and that these should be disposed of in the yellow clinical waste bins provided. They were observed putting up notices to remind all staff. Hawthorn Drive 218 DS0000037656.V293854.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30, The home has an established staff team, available in sufficient numbers that are trained to meet the specific needs of older people and those with a diagnosis of dementia. To protect residents from potential harm a Criminal Records Bureau check (CRB) must be obtained before a new member of staff is confirmed in post. EVIDENCE: In January 2006, the staff roster was changed to create a fairer allocation of shifts. Staff spoken with told the inspector they were happy with the new shift system as it meant all staff were rostered to work weekends and there was a fairer allocation of late and early shifts. Five staff are split across the units each shift, depending on the needs of the residents supported by the team leaders. 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. Staff spoken with felt there was adequate staff to meet the residents needs. The home very rarely uses agency staff, but do have the support of social services home carers (home first) staff to cover staff sickness. In addition to the care staff there are a team of five domestic staff, catering staff and a maintenance person. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 22 Three staff files were inspected and evidence seen that two staff had completed the National Vocational Qualifications (NVQ) at level 2; one has applied to undertake level 3. The third file seen was for a new member of staff. New staff are expected to complete the skills for care induction and foundation. They are issued with a pack, which contains workbooks and written information for the staff to complete set units of work and service user related issues. Evidence was seen that the new member of staff had attended adult protection, confidentiality, communication and skills development courses to help them complete their workbooks. All new staff are monitored during their induction period by an in-house assessor. Hawthorne Drive has six staff who holds an assessor award, all are trained to assess the new skills for care standards. The home has good recruitment procedures in place. Evidence was seen that employment policies and procedures are followed and the three files seen had evidence of a job application, identification, contract of employment, authorisation for appointment and two written references and on two of the files a recent Criminal Record Bureau (CRB) including a check against the Protection of Vulnerable Adults (POVA) register. However the new member of staff had no evidence on their file that a new CRB had been requested or their existing CRB had been transferred to Hawthorne Drive from their previous employment in another local social services home. The senior team leader informed the inspector of a range of training being provided by Otley College. 30 staff have commenced infection control, 4 staff are completing an activities course and 3 staff are in the process of completing diversity and equality training. Individual tutors visit the home to monitor staff’s progress and assess their course work. Records were seen of other training that has taken place in the home. Staff have attended courses or watched a video and completed a question and answer session on a range of topics for example, moving and handling, fire safety, food hygiene and challenging behaviour. The manager has managed to obtain 10 places for staff to attend a working with dementia course through social services and all other staff have completed dementia training. Other training included Control of Substances Hazardous to Health (COSHH) and Unisafe. Four staff had attended Unisafe training in January; another 3 sessions are booked through the course of the year. The home has accessed some free training through Optical Awareness for visual awareness training. Hawthorn Drive 218 DS0000037656.V293854.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,38, Residents living at the home accounting procedures are in safeguarded. Residents can be interests but cannot expect to health and safety. EVIDENCE: The manager has twenty years experience of working with the local authority and has been manager of Hawthorne Drive since 1996. They hold a National Vocational Qualification (NVQ) level 4 in management and care. The manager was on annual leave; therefore the inspector spent time with the senior team leader who was the person in charge during the inspection. They informed the inspector they were currently undertaking a qualification (K100 in Health and Social Care) in preparation to further their career in social work. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 24 can be assured that suitable financial and place and that their financial interests are assured that the home is run in their best be protected by the home’s procedures for Staff spoken with described the manager and management team as approachable and supportive whilst providing a clear sense of direction and leadership that was in the best interests of the home and the residents. The home clearly demonstrated that they promote equality and diversity for employees as well as the residents. Evidence was seen that arrangements had been made to accommodate an employee with a disability. The home has good quality assurance systems in place for residents, relatives and visitors to give feedback about the services provided. Questionnaires are issued to residents, relatives and visitors annually. One of the team leaders has recently taken over the quality audit process in the home. They told the inspector that they collate all information recorded in the home, for example incident/accident reports and medication summaries to analyse systems in place and how the staff are meeting the objectives of the home. This information is used to make improvements to the service. They also hold regular monthly meetings with the residents and consult with social workers and other related health professionals at the resident’s annual review. Residents and relatives are kept informed of information that may affect the future of the home. In the entrance hallway the manager has placed a copy of the Social Services Review for Older People in Residential Care. This is to keep people informed of the review that is currently taking place by Social Services. The manger has also invited residents and relatives to a meeting to keep them up to date with the review and to eliminate fears and rumours. The meeting is to take place with the person leading the review so that they can discuss any issues or concerns. Hawthorne Drive has a detailed adult care and community service business and financial plan, which sets out the home’s vision and commitments for adult services and the priorities and targets between 2005 and 2009. The administrator explained how the home manages the accounting and financial procedures. The budget is set yearly and all invoices are linked into the budget, which are sent to head office for payment. Monthly checks are undertaken to ensure the home is on target to meet the forecast. The administrator informed the inspector that the budget is well managed and the only fluctuation where the budget alters is around staffing. The inspector discussed the process for safeguarding resident’s finances with the senior team leader and administrator. There are only four private paying residents who deal with their own finances. The home manages accounts for residents they receive contributions for and their personal allowances. The administrator oversees each resident’s account and they have a database that provides an audit trail of resident’s expenditure where money is withdrawn and a record of their personal allowances paid in. The accounts are well managed and the current balance for one resident tracked during the inspection was seen and found to be accurate. Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 25 Evidence was seen on staff files that regular supervision takes place. Each member of staff signs a supervision contract, with agreed supervision taking place every 4 – 6 weeks. Discussion with staff confirmed that supervision does happen regularly where they discuss key worker issues, training, personal development and any other issues related to their work in their home. Evidence was also seen that new staff receives additional support sessions at intervals of 9, 18 and 26 weeks as part of their induction. Time was spent with the cook who showed the inspector records of how the home managed the receipt, storage, preparation and cooking of food. The food stores seen held a wide range of dry, fresh and frozen foods. All were being stored appropriately and in line with food safety regulations. Currently the home provides meals on wheels to a small number of people in the community. However this is due to cease and is being taken over by the Women’s Royal Volunteer Service (WRVS). The fire-working folder seen was not up to date. The last recorded fire drill was 28/04/05. Also, there was no record of the recent date that the fire fighting equipment had been tested. Evidence was seen on a fire extinguisher in the corridor by the manager’s office that they had been tested on the 25/11/05. Weekly fire tests were taking place and documentation was available to prove this. The maintenance person carried out the tests included emergency lights and the automatic fire door closures. The Fire alarm system was checked by T & P fire services in March 2006. A separate fire folder contained the updated risk assessment, but also held a lot of out of date information. Hawthorn Drive 218 DS0000037656.V293854.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 2 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 4 4 3 3 X 3 3 4 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 3 3 3 3 3 X 2 Hawthorn Drive 218 DS0000037656.V293854.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 OP2 Regulation 5 (b) (c) Requirement Timescale for action 30/06/06 2. OP29 19 Sch 2 (7) Each resident must have a written contract which includes the terms and conditions of living in the home and reflects the current charge and method of payment. This includes residents using the short-term care respite facility. The home must ensure that 30/06/06 Criminal Record Bureau checks (CRB) are seen and checked against the Protection Of Vulnerable Adults (POVA) register prior to a new employee commencing employment. Regular fire drills must be 30/06/06 undertaken, and include all staff and a record of the duration of the evacuation and outcomes of the drill recorded. 3. OP38 23 (4) (c) (iii) (iv) Hawthorn Drive 218 DS0000037656.V293854.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.V293854.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Hawthorn Drive 218 DS0000037656.V293854.R01.S.doc Version 5.2 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!