Inspection on 05/09/06 for Hawthorn House

This inspection was carried out on 5th September 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 21/08/07

Hawthorn House 06/03/06

Hawthorn House 20/04/05

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 Inspection 5th September 2006 09:30 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 DS0000036095.V309551.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. DS0000036095.V309551.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorn House Address 19 Ketwell Lane Hedon East Yorkshire HU12 8BW 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) 01482 898425 F/P01482 898425 Claire Louise Johnson Charles William Johnson Claire Louise Johnson Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22) of places DS0000036095.V309551.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th March 2006 Brief Description of the Service: Hawthorn House is a privately owned residential home that 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 registered 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 and the accommodation provided is now in one shared room and 20 single rooms, 17 having ensuite facilities. There are two communal lounges, a separate dining room and a conservatory. All areas of the home are accessible 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 and there is a car park at the front of the building and a garden to the rear. The weekly charges are £328.00 to £375.00 and there are additional charges for hairdressing, chiropody, toiletries, bingo, newspapers and magazines and in some cases continence aids. This information was provided by the manager on the pre-inspection document. Information is available about the service through the statement of purpose and service user guide. DS0000036095.V309551.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced site visit that took place over one day from 9.30 am to 5.30 pm with a previous two days inspection preparation. As part of the inspection process, comment cards were sent out: eighteen were returned by relatives and other visitors, three by care managers, and one by a GP. In addition, fourteen service users completed surveys. Responses to this consultation about the service are referred to in the report. The visit consisted of a tour of the premises and a review of documentation, including three care plans and other recording systems. Time was also spent with residents in the communal areas. The inspector spoke to a number of service users and five of these were engaged in longer conversations. Discussions were held with staff, the registered manager, a visitor and a health professional. What the service does well: The home consistently provides good care for the service users who live there. The staff are enthusiastic and committed to providing a high quality service that is focused on the service users experience. One service user said, “I am very satisfied with the care I receive” and the inspector observed one service user saying to a staff member who was attending to her “ I don’t know what I would do without you”. Family and friends that visit the home are made to feel welcome; one said “Guests are made welcome with tea and coffee”. Comments received from relatives were positive; one said, “On all counts we are more than satisfied with the love and care and consideration shown to my mother and all residents at the home”, and another said, “We feel the owners and staff try very hard to look after the people in their care both in terms of day to day requirements and also in making the home a happy place”. The home is well maintained throughout both internally and externally and is very clean and free from odours. This gives the service users a pleasant environment in which to live. One social care professional said “ During visits service users appear content within a calm and pleasant environment”. The manager is committed to providing training to staff and 66 of staff have achieved NVQ Level 2 or above. Training is ongoing and during the last year staff have attended moving and handling, medication, duty of care, food hygiene, protection of vulnerable adults and dementia training. DS0000036095.V309551.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. DS0000036095.V309551.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 DS0000036095.V309551.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): 3,6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are fully assessed prior to being accommodated to establish that their needs can be met. EVIDENCE: Three service users files were examined and all contained an assessment of need that had been completed by the manager prior to service users being accommodated at the home. For those service users who are referred through care management the home obtains a summary of the care management assessment. The assessments assist the manager in making a decision as to whether the home is able to meet the service users needs. Each service user had a plan of care for daily living that is based on the assessment of need. The home does not offer intermediate care. DS0000036095.V309551.R01.S.doc Version 5.2 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): 7,8,9,10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service user’s health, personal and social care needs are fully met. 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 and include activities undertaken, medical assistance and family visits. 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. A service user said, “I know what is in my care plan and the staff follow it. I attend my review”. Eleven service user surveys indicated that they always receive the care and support they need, two said usually and one stated sometimes. One relative said “ I am extremely pleased with the level of care given to my relative” and one said “ My ……… has a number of problems which are dealt with in a sympathetic and professional manner”. DS0000036095.V309551.R01.S.doc Version 5.2 Page 10 Records showed that a service user health needs are clearly indicated on care plans and acted upon. The health professional said, “All the staff show great concerns for the service users care”. The home has policies and procedures in place for administration of medication and staff that dispense medication have attended training. One staff member has responsibility for ordering and checking medication. The home has a monitored dosage system in place. The medication for three service users was checked and these where found to be accurately recorded. 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 should they be required. Medications requiring refrigeration are kept in the homes main refrigerator. Consultation with the pharmacist confirmed that this was appropriate practice. The manager said they liaise closely with the pharmacist for guidance when required. Service users confirmed that the staff at the home respect their privacy and dignity. It was observed that staff knock on service users doors before entering. Privacy and dignity is covered in the staff induction process. A number of service users have their own telephone and a few spoken to said they liked to be able to speak to family and friends on the telephone especially if they lived a distance away from the home. It was observed at the visit that the manager was asking if a new service user would like their own telephone fitted. DS0000036095.V309551.R01.S.doc Version 5.2 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): 12,13,14,15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have choices and control over their lives that helps them maintain their independence. Service users have a well balanced diet and meals are well presented to ensure their dietary needs are met. 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. Service users can access a religious service of their choice. For those who cannot go out, clergy visit the home to see individuals and a service is held in the home once a month. The manager stated that service users go out to different groups such as the RNIB and the WRVS. This was observed during the visit. Records are kept of all activities to ensure stimulation is provided to suit all service users needs. Individual interests are catered for one service user who had an interest in farming was taken to see the sheep during lambing. One relative comment DS0000036095.V309551.R01.S.doc Version 5.2 Page 12 card said “would like to see more visits to places e.g. theatre/places of interest”. 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. All relative and visitors comment cards received advised they are always made to feel welcome. Service users have control over their lives and can make choices. One service user said, “ I can get up when I want and go to my room when I want”. The manager encourages service user to handle their own financial affairs for as long as possible. In the service users guide there is information on how to contact advocates. During the tour of the premises it was noted that service users can bring in their own possessions. The meals provided are varied and presented in an appealing way. The home has two sittings for lunch and staff helped those service users who required assistance in a discreet and sensitive manner. The dining room is well laid out with flowers and napkins on the table. Choices are given for both lunch and tea. The lunch choice on the day of the visit was beef stew and dumplings, sausage plait or salmon salad and for dessert the choice was stewed apple, ice cream or yogurt. Service users said, the food is good and enjoyable. One relative said, “The meals are home cooked and it is as near to being in ones own home as possible”. DS0000036095.V309551.R01.S.doc Version 5.2 Page 13 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): 16,18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are listened to and protected from harm. EVIDENCE: There is a complaints procedure available at the home. There have been no complaints made since the previous inspection. All service users surveys indicated said they know how to complain and that staff listen and act on what they say. Twelve of the fourteen comment cards received indicated that relatives and visitors knew how to make a complaint. The home has the Hull and East Riding adult 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 there has been one Protection of Vulnerable Adults referral that is ongoing but has been dealt with appropriately by the manager, who clearly followed procedures. DS0000036095.V309551.R01.S.doc Version 5.2 Page 14 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): 19,22,24,26 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The standard of the environment within the home is very good providing service users with an attractive place to live. EVIDENCE: The home is located close to the town centre and in easy reach of shops and a bus route. The home is well maintained both internally and externally and is accessible and safe fore service users. There is a programme of routine maintenance available and the home completes monthly audits. The grounds are tidy and safe and service users can access these easily; this was observed during the visit. Some of the service users said that they enjoyed sitting in the garden and explained there had been a summer fair held in the grounds. DS0000036095.V309551.R01.S.doc Version 5.2 Page 15 Service users have access to all parts of the home via a stair lift and a passenger lift. There are a range of aids, hoists and assisted toilets and baths to meet the needs of the individual service users. There is call bell system and the manager advised that this has been maintained with other systems in the home. There was no recorded evidence of this but the manager was following this up. The home provides individual accommodation that is well furnished and comfortable. Service users can bring their own possessions into the home and rooms reflected personal taste; this was observed during the visit. There was evidence that service user’s private accommodation had been fitted with locks. Service users are provided with a key unless a risk assessment suggests otherwise. There is lockable storage available in the service users’ rooms for medication, money and valuables. One service user said, “This is the next best thing to my own home”. The home is clean and hygienic and free from offensive odours. The laundry facility includes hand-washing facilities and washing machines have the specified programme to meet disinfection standards. The home has a policy on the control of infection. There is a risk assessment in place for both the kitchen and the laundry but these did not include information about access to these areas by service users. In addition, the cupboard containing cleaning materials is located in the kitchen/laundry entrance and was not locked. These were dealt with during the inspection process. DS0000036095.V309551.R01.S.doc Version 5.2 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 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The procedures for the recruitment and selection of staff do protect 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 evening, and two during the night. In addition to care staff, domestic and catering staff are employed. Staff indicated that they are 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. Eleven service user surveys indicated that staff are available when they need them and three stated they are usually available. Three staff files were seen and these contained CRB checks. One staff file had only one written reference. This staff member had been in post for two years and the manager advised current practice for new staff is that two written references are sought. Prospective staff complete an application form when applying for posts. It is recommended that gaps in employment records are explored. DS0000036095.V309551.R01.S.doc Version 5.2 Page 17 All members of staff receive induction training and evidence of this was seen on staff files. Staff are offered a range of training and are presently completing a comprehensive health and safety course. The home have 66 of staff that have completed NVQ Level 2 or above in care. DS0000036095.V309551.R01.S.doc Version 5.2 Page 18 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): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. 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: The registered manager is also the registered provider and holds an NVQ Level 4 in care and management. There are clear lines of accountability within the home and there are two deputy managers, senior care staff and care staff. There is a job description available for the manager identifying the role and responsibilities of the post. The staff feel well supported by the manager and said they can go to the manager at any time with any concerns. The home has a quality assurance system in place and has been awarded Parts 1 and 2 of the East Riding of Yorkshire Social Services Quality Development DS0000036095.V309551.R01.S.doc Version 5.2 Page 19 scheme. The home seeks the views of service users via meetings, quality surveys and reviews. Other stakeholders views are also sought including relatives and friends. There are written records of all transactions with regard to individual service user’s money. The inspector checked monies held for three service users and found this to be correctly recorded. Secure facilities are provided for the safekeeping of money and valuables on behalf of the service users. The home has policies and procedures available for safe working practices. The home had up to date maintenance certificates available. These include electrical installations, portable appliance testing, lift, hoists, fire alarm and emergency lighting certificates. There are risk assessments in place for the premises and a fire risk assessment. The accident book was checked 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. DS0000036095.V309551.R01.S.doc Version 5.2 Page 20 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 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 4 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X 3 X 4 3 3 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 X 3 x 3 X X 3 DS0000036095.V309551.R01.S.doc Version 5.2 Page 21 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. 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 2 Refer to Standard OP22 OP29 Good Practice Recommendations Evidence that the nurse call system has been maintained should be in place. Gaps in employment records for prospective staff members should be explored. DS0000036095.V309551.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Hessle Area Office First Floor, Unit 3 Hesslewood Country Office Park Ferriby Road Hessle 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 DS0000036095.V309551.R01.S.doc Version 5.2 Page 23 - 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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