Inspection on 04/01/06 for Hawthorn Drive 218

This inspection was carried out on 4th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hawthorn Drive 218 23/06/09

Hawthorn Drive 218 12/09/07

Hawthorn Drive 218 24/05/06

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 Helen Fontaine Unannounced Inspection 5th January 2006 11:00 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.V276471.R01.S.doc Version 5.1 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.V276471.R01.S.doc Version 5.1 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.V276471.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st June 2005 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, sixteen 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 access, staffing and accommodation. The homes kitchen also provides a community meals service on a daily basis. Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of 218 Hawthorn Drive took place over five hours and was the second statutory inspection visit in the inspection programme for 2005/6. Over the course of the two visits, all core standards have now been assessed. For one requirement; Standard 7, made at the time of the last inspection on the 1st June 2005, has not yet been met and has been restated in this report with a new timescale for compliance. A tour of the home was undertaken with the senior team manager and various documents provided by the homes manager were looked at. Four residents and one member of staff were spoken to individually. The assistance of the senior team manager and the homes manager was very much appreciated. What the service does well: What has improved since the last inspection? Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 6 The home has continued to provide the residents with the highest quality of care. 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.V276471.R01.S.doc Version 5.1 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.V276471.R01.S.doc Version 5.1 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): These standards were not inspected on this visit. However evidence from the last inspection was that, the home continues to operate a detailed preadmission and assessment procedure, which helps to ensure that the needs of individual residents can be met by existing service and facilities. The home offers prospective residents an opportunity to “sample” the service on offer before making any firm decision on whether they wish to become a permanent resident. EVIDENCE: The above standards were not specifically examined on this visit, as there were no outstanding requirements in relation to Choice of Home standards 1 – 6. Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 10 and 11 Service users do have a care plan but these are not reviewed. Service Users are assisted to access community health services. Service users feel that they are treated in a respectful manner and their privacy is upheld. Residents can expect to have their wishes respected at the time of their death. EVIDENCE: Residents care plans were looked at and each of the files looked at had good comprehensive care plans. However the reviews were looked at and found on the files looked at that the reviews had either not taken place, or it had not been documented. This is a repeat requirement from the previous inspection, the manager is aware and has been talking to the senior carers that these must take place and be documented. During the inspection a tour of the home was undertaken, staff were observed using the residents preferred name and introducing the inspector by name to any residents that was talked to. No resident’s rooms were entered without permission of the residents and all bedrooms had a key, allowing the residents to lock their rooms if they wish. Each door to the rooms were either numbered and/or had the persons name or an article of the residents choice. One door seen had a string of small bells on the door; some of the other doors had no Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 10 visible name or picture. Visiting health specialists, GP’s and District Nurses, visited the residents in their own rooms. Care plans of two residents were looked at and the section around aspiration was checked. One was documented, would like to remain independent, accepts that the pain is being managed as far as possible, enjoys a cigarette and is documented that it helps to keep them going. The other resident wanted to be as independent as possible and it was documented that they needed to feel relaxed in the home. The admissions perception was that they wanted to be in this particular home as they had relatives living locally and needed to feel secure and safe. The care plan also documents other areas of choice and as an example, one resident likes fresh juice in their room and some biscuits, but needs the juice changed daily. Other things the resident like to do was documented as watching the Television or videos and go on outings as well as still enjoying reading. Another separate section in the care plan was “my final wish”, it had the name of the resident and is documented “after talking with the resident they made it quite clear that they wish to be buried”. It continues that they do not wish to be cremated, that they have requested flowers at their funeral. The document states that the resident likes Sun Flowers, Chrysanthemums and daffodils if it is spring. The hymns the resident likes were documented as “Eternal father strong to save” and “All things bright and beautiful”. It is documented that the resident would like the Co-Op funeral directors and the document is signed by the resident. The other care plan looked at documents that this residents wishes to be cremated and would prefer the Co-Op funeral directors to make the necessary arrangements, initiated by the staff at the home. Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 14 People who use this service can expect to be encouraged to choose how they spend their time. EVIDENCE: All residents in the home have their own keys to their rooms and choose if they wish to have their personal allowance paid directly to them. The home encourages all residents to exercise choice and control over their lives. One resident spoken to said that they did like to get out and had been out to the local pub with another resident. Another resident had been to the day centre at the home and had won a prize. When asked what they would do with their prize, they said that they would give it to a friend. The residents care plans documented what they liked to go to bed and get up, how many times the resident would like to be checked through the night. The care plan also documented whether the resident liked their room door open or shut at night. Two residents spoken to had been neighbours before moving into the home and had chosen to move into the home together. One of them had their family member visit and as both residents knew each other well, they knew their family members as well. The two residents had chosen to sit together in the small quiet lounge, they felt that they did not need or want to take part in activities. Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 People who use this service can expect that they will be protected from abuse EVIDENCE: The home has robust policies and procedures on adult protection and as a Local Authority home can access the training and other support. Residents spoken to all said that they felt very safe and when asked said that any complaint or concern, they would be sure would be thoroughly looked into. One of the residents said that if they had any problems they would go straight to the senior and felt any cruel staff would be dealt with very quickly if the situation arose. Staff members talked to, were aware of the policies on adult abuse but were very clear that in their opinion all the residents were very safe living in the home. Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not tested on this visit. However evidence from the last inspection was that the home provides a high standard of both private and communal accommodation to residents. There is a continued programme of redecoration and renewal and residents have the benefit of living in smaller units in a relaxed and comfortable environment. EVIDENCE: The above standards were not specifically tested on this visit, as there were no outstanding requirements in relation to the environment standards 19 – 26. As in the previous report the home continues to exceed the National Minimum Standards. Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 14 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): 29 and 30 The home recruitment practices are robust and offer protection to service users. Staff are trained to do their job. EVIDENCE: During the inspection two staff files were looked at for the newest members of staff. The documentation had a photo of the member of staff, personal details, induction sheet, with first day in post with tour of the building with a list of information given to the member of staff. On the file was the employment particulars, medical questionnaire, banking details, memo for an identity badge, memo on night working, with a food-handling documents, which was signed. In the staff files were all the employment policies and procedures, job application and supervision records from the time they commenced with the home. The supervision section had a supervision contract, with the agreed supervision taking place every 4 – 6 weeks and signed by the worker and the senior. Supervision record documented that this member of staff had their last supervision session on 20th December 2005 and had the next supervision session documented as 2nd January 2006. On the files was the first nine-week report and the eighteen-week report and documented areas of support needed and it was seen that these were also discussed during supervision. The staff files showed that these members of staff had undertaken the carers foundation training, which included value base, unisafe, abuse, work development, fire prevention in the care home July 05, managing challenging behaviour and a number of other training courses. The staff file also had the contract of employment, sick certificates, leave forms, authorisation for Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 15 appointment, Criminal Record Bureau check, two references, identification and Prevention of Vulnerable Adults first check. Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 16 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 and 38 This home is well managed and there are clear systems in place to protect service users. EVIDENCE: The home has undergone a Local Authority accreditation exercise and this involved undertaking an audit of residents and visitors view of the home. The home had also undertaken an exercise before Christmas, getting the wishes of its residents over the meals and activities during the festive season. The home devised a small questionnaire, which the residents completed about what they wanted for Christmas Eve, Christmas day and Boxing Day to eat. This also included where they wanted these meals to take place and following this exercise, a laminate menu for each day was produced. The quality assurance and quality monitoring exercise, was undertaken by a questionnaire. This had some eight questions with a yes, no or sometimes ticks box exercise to the questions. The questions were: Has anyone at Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 17 Hawthorns talked to your, do you feel staff tell you enough about what is happening in your situation and do you think that information provided to you at Hawthorn Drive is relevant to your needs and is up to date. Another question was do you know how to make comments, complaints about service you are getting. The inspector looked at the completed questionnaires and most were answered yes. During the inspection issues around the residents finances were looked at and the home do not deal with any issues over pensions. The home does give out personal money, or bill the relatives for extra’s the residents have had. Some relatives give their family members the money they might need to buy things and some residents deal with their finances independently. Residents do have a bedside cabinet with a lockable drawer, where residents if they wish can keep their money or valuables. The home have a data base with the money that residents have, this shows the amount given out to each resident and these are signed and witnessed by the resident and a member of staff. The homes procedures and practices around Health and Safety are to be commended. The paper work is kept to a very high standard and everything is properly documented and maintained. The homes security of premises was looked at and observed that visitors coming to the home are seen by staff through a window, before they are allowed through the door. Visitors coming to the back of the building and the car park, have to have a swipe card that lets them into the car park and then access to the back of the home. The first floor access up the main stairs has pressure pads on the stairs that releases the door at the top of the stairs and alerts staff to anyone coming and going from the area. Other stairs are accessed through a door again with a swipe card and then a gate on the top of the stairs. The home has the Local Authority on accidents with forms that are completed and recorded. Documents seen indicating that dates were serviced or checked, Fire protection certificate and Fire extinguishers 25/11/05, fixed portable electrical appliances testing 15/10/04, Rotowash machine services 14/1/205 and Appollo assisted bath service 7/7/05. The hoist and other equipment including the lift certificate on 10/5/05, all the kitchen equipment 27/9/00 and the home does its own monthly Health and Safety inspection. This inspection covers kitchen, dinning room/lounge, laundry room, bathrooms, staff room, corridor, laundry cupboard and small dinning room. The water temperatures were all checked each week and documented that on one unit the temperature ranged from 37° - 34° C another documented as 32° - 37° C, the manager said it depends on which part of the building it is tested. The manager is aware that this is rather a big range for the temperatures; the home has had a company in to look at this and they renewed the boilers. The gas boilers had a service check on 13/4/05, the Food hygiene was inspected on 24/11/04, the gas safety check was done on 27/7/04. A point of work safety assessment report and work repair was done on 16/5/05, kitchen servicing Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 18 6/1/04 kitchen deep cleaning 10/1/05, ultra violet fly killers 16/3/04 and a certificate from the Council control dated 31/5/02 The whole home is very well run and the manager and all the staff have put a great deal of effort and hard work to maintain a good quality of care for the residents. Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X X X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 X 9 X 10 3 11 4 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 X 14 4 15 X COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 4 X 3 X X 4 Hawthorn Drive 218 DS0000037656.V276471.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(2)(b) Timescale for action The Registered Persons must 04/04/06 ensure that evidence is available to comfirm that resident care plans are reviewed at a frequency as detailed under Standard 7.4 of the National Minimum Standards. This is a repeated requirement. Requirement 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.V276471.R01.S.doc Version 5.1 Page 21 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.V276471.R01.S.doc Version 5.1 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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