Inspection on 20/04/05 for Hawthorn House

This inspection was carried out on 20th April 2005.

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 21/08/07

Hawthorn House 05/09/06

Hawthorn House 06/03/06

Hawthorn House 13/01/05

Hawthorn House 03/08/04

Hawthorn House 27/01/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE Hawthorn House 19 Ketwell Lane Hedon East Yorkshire HU12 8BW Lead Inspector Lynne Busby Unannounced 20 April 2005 09:15 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 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 House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Hawthorn House Address 19 Ketwell Lane, Hedon, East Yorkshire, HU12 8BW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01482 898425 Mrs Claire Louise Johnson & Mr Charles William Johnson Mrs Claire Louise Johnson Care Home 20 Category(ies) of OP Old age, DE(E) Dementia - over 65 registration, with number of places Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 14/01/05 Brief Description of the Service: Hawthorn House is a privately run residential home. It is close to the town centre of Hedon. The home is close to the main road and access to public transport. The home has a minibus available to take service users on days out. The home is regsitered for 22 people over the age of sixty five of either sex. It also provides for those service users who may have dementia. The home has recently had an extension built to the rear of home. The accommodation provided is now in 1 shared room and 20 single rooms, 17 have ensuite facilities. There are two communal lounges, a separate dining room and a new conservatory. All areas of home are accesible to service users via the provision of a stair lift and a passenger lift. The latter was installed at the same time the extension was built. The home is well maintained there is a car park at the front of the building and a garden to the rear; the garden is presently being landscaped. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place over 7.5 hours. The inspection process included a review of documentation and a tour of some of the building. The inspector spoke to two of the staff on duty, the manager, one of the providers who deals with all the maintenance, thirteen of the twenty-two residents, and eight families and friends who were visiting and a district nurse. What the service does well: What has improved since the last inspection? What they could do better: Whilst the health care of service users is very good, closer attention needs to be paid to the recording of medication. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 6 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 House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 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 standard(s) 2,3,5 Prospective service users are given opportunities to make a considered choice before being accommodated. EVIDENCE: All new service users are provided with a copy of a written contract or statement of terms and conditions with the home. This is provided at the point of moving into the home. Individual records are kept on each of the service users and inspection of the records of three files, one who was a recent admission, had full assessment information recorded on them. This included an assessment completed by the home and, for funded service users, a community care assessment. In addition to this the records included a plan of daily care. For the most recent admission there was only a temporary plan in place and this was not in the same depth as other plans of care. This was because the service user was making a decision whether they would like to stay permanently. Once this decision was made a permanent plan would be completed, if required. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 9 One service user who had been recently been admitted to the home advised that they had come to look round the home first and viewed the room that was available. Service users can stay for meals. This gives the prospective service user an opportunity to make a considered choice. Service users are admitted on a trail basis and this can be extended if a service user is undecided. The home does not take emergency admissions. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 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 standard(s) 7,8,9 Service user’s health, personal and social care needs are fully met. Service users health needs are closely monitored. EVIDENCE: Individual plans of care were available on the three files seen. Aspects of health, personal and social care needs are identified and planned for. Daily records clearly identified significant events. Recorded accidents were crossreferenced to the accident book for one service user. The plan of care is generated from the home’s assessment of needs or the community care plan. The plan is reviewed by the keyworker. The service user or their representative signs the plan. During the inspection two service users had reviews that they attended. Records showed that service user health needs are clearly indicated on care plans and acted upon. One service user had a problem that required a district nurses attention. The manager dealt with this straight away. The district nurse confirmed that the staff respond quickly and contact the district nurses when necessary. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 11 Three service users’ medication was tracked. All were recorded and accurately dispensed with the exception of one medication for one service user. This had been given but not signed for. The manager rectified this on the day of the inspection. There is one service user who self medicates; safe storage is available and staff monitor this. There are presently no controlled drugs but systems are in place if it is required. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 12 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 standard(s) 12.13 Service users are able to take full advantage of activities and interests and participate in community and family life. EVIDENCE: Activities are arranged for each morning and the programme is displayed on the notice board. A range of activities including, quizzes, bingo and craft sessions are provided along with external entertainers who visit the home. Service users explained they could join in if they wish. In addition to activities some service users go to a religious service of their choice. For those who cannot go out clergy visit the home to see individuals. Several service users said they go out to different groups such as the RNIB and the British Legion. Staff ensures that service users special occasions are honoured. On the day of the inspection a birthday was being celebrated and the small lounge was made available for family and friends to have a birthday party. Records are kept of all activities to ensure stimulation is provided to suit all service users needs. Family, friends and other visitors can see service users at all reasonable times. Service users can choose who they see and can receive visitors in private. Family and friends all advised they are always made to feel welcome. One family said “ nothing is to much trouble for the staff”. There is written information for relatives and friends and representatives of the service users that is given at admission and reviews. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 13 Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 14 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 standard(s) 16,18 Service users are listened to and protected. EVIDENCE: The home has a complaints procedure available. There have been no complaints made since the previous inspection. Service users said they know how to complain and the manager dealt with any complaints/concerns quickly. The home has the Hull and East Riding protection procedures manual and its own written procedures. Staff spoken to demonstrated an awareness of ‘whistle blowing’ to protect service users and had completed training on protection of vulnerable adults during the completion of the NVQ award. Since the previous inspection the manager has attended the training on Protection of Vulnerable Adults. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 15 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 standard(s) 25,26 The home is clean, hygienic and well decorated. The service users live in a safe and comfortable ‘homely’ environment. EVIDENCE: The service users rooms are centrally heated and pipework and radiators are guarded with the exception of two, which is at the service users request. This is documented on individual files. This is being closely monitored. Since the previous inspection the water temperatures are regularly taken and recorded in addition a number of washbasins have been fitted with pre set valves. This work is continuing and the provider advised that this work would be completed within the next 6 weeks. The home is very clean, bright and free from offensive odours. The home has policies on infection control and recently all staff have completed infection control training. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29 The procedures for the recruitment and selection of staff are robust and offer protection to service users. Staff are employed in sufficient numbers to meet the service users needs. EVIDENCE: There is a staff rota available that indicates that there are three staff on duty in the daytime and two during the night. In addition to care staff, domestic and catering staff are employed. Staff indicated that there was enough time to be able to spend time with service users on a one to one basis or in groups. Service users advised that staff were always available and when call bells are used they are answered quickly. Three staff files were seen and these contained CRB checks and written references. Discussion with the manager indicated that she is aware of the need to check gaps in employment and validity of references. References are sent to the referee directly from the home. The home does not accept references that have been previously written e.g. ‘to whom it may concern’. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35,38 The home is managed well and run efficiently. It provides an environment that is safe and the welfare of staff and service users is promoted. EVIDENCE: Three service users finances were checked and these were appropriately recorded. Each service user had their monies stored securely. Some service users choose to handle their own finances. Safe storage is provided in individual bedrooms. The home have up to date maintenance certificates available. There are risk assessments in place for the premises and a fire risk assessment. The accident book was checked and cross referenced to service users’ files and found to be appropriately recorded. Staff have attended a range of training including fire awareness, moving and handling, basic food hygiene and safe medications. First aid training is ongoing. Since the previous inspection the fire officer has Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 18 visited and made a number of recommendations. The home have provided CSCI with an action plan of how these will be met. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 3 3 x 4 x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 x COMPLAINTS AND PROTECTION x x x x x x 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 3 x x x x 3 x x 3 Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 20 No 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. 1. 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 9 Good Practice Recommendations Medications administered should be clearly recorded. Hawthorn House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Unit 3, Hesslewood Country Office Park Ferriby Road Hessle, East Yorkshire HU13 0QF 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 House J53_s36095_Hawthorn House_v221969_200405_Stage 4.doc Version 1.30 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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