Inspection on 18/12/06 for Hawthorn House

This inspection was carried out on 18th December 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 House 12/11/08

Hawthorn House 06/02/06

Hawthorn House 25/07/05

Hawthorn House 05/01/05

Hawthorn House 02/09/04

Hawthorn House 10/03/04

Similar services:

Polesworth Group 68 Long Street

10 Whitfield Avenue

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

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

CARE HOME ADULTS 18-65 Hawthorn House Burton Old Road West Lichfield Staffordshire WS13 6EN Lead Inspector Mrs Wendy Grainger Key Unannounced Inspection 18 December 2006 09:45 Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 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 House DS0000030294.V321927.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 Adults 18-65. 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 House DS0000030294.V321927.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorn House Address Burton Old Road West Lichfield Staffordshire WS13 6EN 01543 252211 F/P 01543 417499 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) Staffordshire County Council, Social Care and Health Directorate Suzanne Morris Care Home 29 Category(ies) of Dementia (10), Dementia - over 65 years of age registration, with number (10), Learning disability (29), Learning disability of places over 65 years of age (15), Mental disorder, excluding learning disability or dementia (4), Mental Disorder, excluding learning disability or dementia - over 65 years of age (4), Physical disability (20) Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6 February 2006 Brief Description of the Service: Hawthorn House is a Local Authority home within the residential area of Lichfield and provides long-term care and support for twenty nine adults with a learning, physical disability and more complex needs including sensory disabilities, challenging behaviours and mental health issues. The home consists of two buildings, both purpose built and provided care within four separate units. Upper and Lower Hollies provide twelve bedrooms and Upper and Lower Rowans provide sixteen bedrooms. Both units have a ground and first floor. Each unit consists of three communal lounge/dining areas kitchen or basic kitchen facility, bathroom, shower room and each individual had a single room. There is an industrial kitchen and laundry room in each building. In Upper Rowans, the unit has a small flat where service users are supported to live semi-independently. Lower Hollies provides a six bedded special care unit for service users with more profound disability problems. Service users have access to Lichfield Day Services. . Information provided in the pre inspection questionnaire identified that the current cost of a placement at Hawthorn House was £706. Residents would be expected to fund any private purchase including holidays and outings. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors completed this key inspection on the 18 December 2006. the key areas were inspected, residents were spoken with as were the staff on duty. The registered care manager provided the inspectors with records, reports and documents. A sample tour of each building was included in the inspection. The registered care manager and the staff assisted inspectors with the inspection. What the service does well: What has improved since the last inspection? Arrangements had been made for some bedrooms to be decorated since the last inspection in February 2006. This is an on going programme, corridors and staircases were planned for early 2007. There had been new appointments for care staff since the last inspection. The procedure for recruitment and employment had been followed for each person as required by the National Minimum Standards. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. standards 1,2, This judgement has been made using available evidence including a visit to this service. The statement of purpose was made available. There was a need to rephrase the admission process within the Statement of Purpose to ensure it includes the required assessment by management prior to admission. EVIDENCE: The Statement of Purpose had some information that was not relevant to the current status; this needed to be updated when the relevant information was available. The section for the pre admission process would benefit from rephrasing to include the full assessment of the management team. There have been one admission since the previous inspection; the home did not cater for respite care. Any person being admitted to Hawthorn House would be assured that they could continue their life style with the support of the experienced and committed staff. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 6,7,8,9,10 were reviewed This judgement has been made using available evidence including a visit to this service. Access to care plans, speaking to staff and residents. Arrangements were in place for any person to access medical treatment from other professional agencies. Care plans were detailed and continue to provide current appropriate information on individuals. EVIDENCE: Samples of the care plans were seen in both homes. They were detailed and contained relevant information to enable the staff to support individuals in their life style. It was recommended that an index would assist staff easy access; especially in the event of new staff commencing employment. Each care plan evidenced risk assessments; it was recommended that one person who chooses to bath alone had an addition to his risk assessment to ensure safety while respecting his wishes. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 10 Comments on the day and from the “have your say about” received from the residents indicated that teach person was very satisfied with their home and the care that they were provided. Not all the residents were able to make a verbal comment, staff would use alternative methods and observe body language in the event they had concerns. Residents in both homes were well presented, staff were seen to assist when appropriate in a caring manner based on their knowledge of the individual. Access to all other professional agencies was evidenced in the care plans, some appointments out of Lichfield could incur a cost for transport for the resident. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is excellent. Standards 12,13,14,15,16,17. This judgement has been made using available evidence including a visit to this service. Speaking to the staff and residents access to residents records. All the residents, supported where necessary by experienced staff, experienced a full and active social life. Menus evidenced, identified a balanced varied diet to suit individuals needs. EVIDENCE: A number of the residents had experienced a holiday during the year. Access to specially adapted facilities had been used. Some of the older residents preferred to have days out returning home at night. This would be organised by the link person to the resident. Residents were independent and funded their own holidays. Staff support holidays which was counted as part of their Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 12 working week, funding was arranged from the comforts fund or contributions to the holiday. The staff promotes daily living skills in house; the day centres also promote individual skills including gardening, cooking and woodwork. Links with the community and families were part of the continued life style for residents. Menus evidenced offered choice for all the meals served. Special diets were provided when necessary. Mealtimes were somewhat flexible to meet the external social life of residents. No meals were reheated fresh food would be prepared. The inspector evidenced one member of staff assisting a resident with lunch. This was done in a sensitive manner while sitting with the resident. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): . Quality in this outcome area is good. Standards reviewed 18,19,20. This judgement has been made using available evidence including a visit to this service. Speaking to staff in respect of the medication process and access to other professional agencies. Arrangements and support were evidenced to enable residents to access other professional agencies. Staff had received the appropriate training for the administration of medicines. EVIDENCE: Medication was secured appropriately, the staff spoken with confirmed that they had received relevant training for the administration of all medications. No resident had the ability to self administer his or her medication. Care plans evidenced that residents had access to medical services in Lichfield and elsewhere. Each and every one the residents have a half yearly check up for their health. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 14 The relevant equipment had been provided to meet residents needs. This equipment was serviced on a contractual basis. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good, Standards reviewed 22,23 This judgement has been made using available evidence including a visit to this service. Reviewing the complaints process, and training for staff. Residents were protected from any form of abuse by committed staff and the care provided. The complaints process for residents was contained in the care plan. EVIDENCE: The commission or registered care manager had received no complaints against the service or employees. Resident’s comments indicated that they were listened to and would know who to voice any concerns. The more dependant resident’s personalities and body language were observed for any changes that may indicate they were unhappy. The inspectors were told that the complaints process was being reviewed to enable resident’s easier access. Staff as part of their on going awareness undertake appropriate training to ensure that residents were protected from any form of abuse. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 24,25,27,30 were reviewed. This judgement has been made using available evidence including a visit to this service and tour of the home. Residents were provided with a warm, comfortable and well furnished environment within each of the houses. EVIDENCE: Both houses were sampled, the high standards of hygiene continued to be provided. The housekeeping staff should be congratulated. Resident’s bedrooms were sampled and evidenced that they had the option to personalise their private rooms. One resident has two cats that are her responsibility and share her room. The registered care manager recognised that there were areas that need attention to decoration. It is planned that the corridors and stairwells in the lower house are decorated in 2007. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 17 Residents spoken with told the inspector that they were happy and liked living at Hawthorn. Staff supported and discussed changes they may wish to make to their rooms. There was a concern discussed with the manager regarding a resident in the top house who has recently returned from hospital. He has on occasions a mobility problem; and while there is a small chair lift in the top house he has experienced difficulty in using it. The staff over the weekend have taken him out and around the building to get him into the lounge. This is not acceptable and an alternative method was discussed. The manager will consider using a transfer board as a the short term measure on this residents off days when he cannot weight bare. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 31,32,34,35, This judgement has been made using available evidence including a visit to this service. the recruitment process and staff records were made available. The home had a proactive staff training programme to meet the needs of the residents. Staffing levels were appropriate for the times of the day to support the residents life style. EVIDENCE: Staffing levels fluctuated during the day recognising the daily routines and needs of the residents. Each of the homes had a manager supported by staff, catering and housekeeping staff. Recently due to illness the night staffing routine had been adjusted with an extra person awake in the top house. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 19 Since the previous inspection the home had recruited new staff. There were no vacancies for staff at the time of this inspection. Staff records evidenced that the recruitment, employment plus induction and training had followed the National Minimum Standards. The registered care manager made available the training programme undertaken by the staff in 2006 and the future plans for training in 2007 obligatory training was current and on going. The registered care manager is on line to complete the Registered Managers Award in 2007. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. Standards 37,38,42,43. This judgement has been made using available evidence including a visit to this service. Records, reports and documents were made available. Hawthorn House was operated in a manner that was beneficial to all the residents. Residents were protected by the structured procedures and training of the staff. EVIDENCE: Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 21 To comply with the new fire requirements the home is to undergo major work to install the appropriate equipment in the loft space. Records for the prevention and process of staff training were current. The one recommendation made on the previous inspection had been addressed. Discussed with the registered care manager was the need to develop the contingency plans in the event of an emergency when residents could not access the homes. The handyperson maintained clear monthly records for the testing of the water temperatures. One concern of a high temperature has been reported to the appropriate firm to adjust. The inspectors were impressed with the knowledge of the registered care manager and her staff as to the needs and daily routines of the residents. Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 3 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 3 28 X 29 X 30 4 STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 4 3 X X X 3 3 Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 23 N/A Are there any outstanding requirements from the last inspection? 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA1 Good Practice Recommendations To rephrase the admission process to include the management assessment prior to admission of a new resident. To remove the no relevant information in respect of the responsible person until current information is available To consider having an index at the front of the care plans. To prepare a record for any resident that has a structured turning programme in respect of their health needs. To further develop the continence plans in the event of an emergency when neither home can be accessed. 2. 3. 4. YA6 YA6 YA42 Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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. Extracts may not be used or reproduced without the express permission of CSCI Hawthorn House DS0000030294.V321927.R01.S.doc Version 5.2 Page 25 - 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. 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