Inspection on 06/02/06 for Hawthorn House

This inspection was carried out on 6th February 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 18/12/06

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 Unannounced Inspection 6 February 2006 13:30 Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 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.V276712.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 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.V276712.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hawthorn House Address Burton Old Road West Lichfield Staffordshire WS13 6EN 01543 252211 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.V276712.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th July 2005 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. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was completed with the Head of Home, residents and staff on the afternoon of the 6 February 2006. Information for this report was from the reports, records and comments made by the residents. Observations of interaction of staff and between the residents, a sample tour of the home assisted the completion of the report. At the time of the inspection there were twenty-seven residents at home. The management and staff provided a service and support for people with a learning disability. Accommodation is in two separate buildings each with its own team of staff. The offices for administration were located in the Lower House. The home had developed a new Statement of Purpose reflecting all the elements to comply with the National Minimum Standards. Access to the community, day centres, and medical consultation continued as appropriate. This report will cover areas not explored in the previous inspection with some core standards. What the service does well: Each house provided an exceptional standard of hygiene. Resident’s comfort was considered and evidenced with the fixtures and fittings, on going decoration continued. Staff demonstrated their skills and commitment to each individual supported by them. There was a relaxed atmosphere within the homes, coupled with light banter in the top house. Relaxation in the form of aromatherapy was provided weekly, this was evidenced during this inspection. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 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. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 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.V276712.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,3 The homes documents and procedures for assessment continued to provide all the relevant information for a placement. EVIDENCE: The inspector was provided with a copy of the new Statement of Purpose, which identified all the elements required in the National Minimum Standards. There had been no new admissions to Hawthorn House for sometime, in the event of an enquiry the management would assess via the method suited to the individual. Ensuring that they were aware that their life style could continue with the support of the staff. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,8,9,10 The care planning system provided staff with the appropriate information they need to satisfactorily meet the resident’s needs. Arrangements for access to other professional agencies were in place. EVIDENCE: Access to external professional agencies continued, recently the speech therapist had been involved in one persons care. This information was evidenced within the sample of care plans seen. The plans were well formulated and in modules; records evidenced that they contained a copy of the complaints procedure, reviews and risk assessments. The management had conducted a 10 survey of the residents as part of the feedback response on the service provided. Each one evidenced that the individuals were satisfied. Residents meetings were arranged and attended by the residents who were aware that they could offer their opinions. Where necessary an alternative format would be used for the less able residents. Residents were supported in their chosen life style, calculated risks were part of this life style. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13,17 Links with the community and friends were part of the life style for residents, their choice was supported by the staff team. Menus and comments from residents confirmed that meals were varied and based on their likes. EVIDENCE: Residents by choice go into the community, this may be independently or supported by their support worker. Links with families and friends were maintained and encouraged. Activities, interests and hobbies were part of the care plan and reviews. Each house had its own kitchen where qualified cooks prepare meals to suit individuals needs based on the comments from the residents meetings. Special diets and meals that need to be monitored were prepared. Observed during the inspection were home made cakes and tarts ready for tea. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 11 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 The committed staff at Hawthorn supported all the residents in their choice of life style. Arrangements were in place for any individual to access other professional agencies. Resident’s safety was protected by the robust policies, procedures and training for medication. EVIDENCE: Within the lower house residents daily routines were based on a normal life style, these residents remained at home. At the time of this inspection the weekly aromatherapy session had just finished. Residents were relaxed in their home; one resident took the inspector to see the units’ cats that spend much of their time in her room and on her bed. Resident’s health care and emotional needs were recognised and respected by the committed staff team. This was evidenced within the care plans. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 12 The appropriate equipment required to support a resident had been assessed and provided. No resident had the ability to self –administer his or her medication. Medication was stored appropriately, signed for and disposed of via the pharmacy. Staff had received a new medication procedure/policy, all the management had undertaken training to ensure the safe handling of medicines. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Residents were protected from abuse by the trained staff and were made aware from documents in their care plan that a complaints procedure was available. EVIDENCE: Evidenced in the care plans seen were documents in the appropriate form to ensure that individuals knew the complaints process. This would be reenforced in the residents meetings. The Commission or the Head of Home had received no complaints. On going staff training to protect the residents rights, and from any form of abuse continued. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 14 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,30 The resident’s home environment was comfortable, warm and a safe place to live. EVIDENCE: Both houses were seen and a sample tour of the homes made. Exceptional hygienic standards were observed. Resident’s bedrooms were filled with personal items of their choice/interests. Bathing facilities were located on each floor and near to bedrooms. Lounge areas were comfortable and designed to provide space for individuals who were less mobile. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 15 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36 Staffing levels were appropriate to meet the needs of the resident groups. The on going training and commitment by the staff ensured that residents were well cared for. EVIDENCE: Staffing levels during the inspection increased with staff coming on duty for when the residents returned from their various colleges/daycentres. The total of staff over twenty-four hours included the Head of Home, one manager, seven support carers, two cooks, four housekeeping, Head of Hotel. The night shift includes two waking staff in the lower house with one waking and one sleeping in staff in the top house. This combination recognised the needs of residents. Staff confirmed that supervision of their development needs were regular. Staff training was on going and current, a matrix was used for quick reference and evidenced during the inspection. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,42 The management and the staff operated the home in such a manner that residents were protected and provided a safe environment and life style. EVIDENCE: There was a relaxed atmosphere in each of the houses. Light hearted banter with residents was instigated from a comment by the inspector. Residents responded quickly; life went on as normal, one resident had celebrated her birthday and told the inspector that she was going to have her hair done the following day. The manager cascaded her skills and was part of the staff team but not on the working rota. She had commenced the NVQ in Management and Registered Mangers Award. The records for the prevention and protection in the event of a fire were current and well maintained. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 17 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 X 3 3 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 3 25 4 26 4 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 X 15 X 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 X Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 18 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 YA17 YA43 Good Practice Recommendations To date all the food stored in the freezer and to maintain the food in the original packages. For the staff involved in a fire drill to sign the records personally. Hawthorn House DS0000030294.V276712.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 DS0000030294.V276712.R01.S.doc Version 5.1 Page 20 - 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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