Inspection on 08/08/07 for Hawthorn House Short Break Service

This inspection was carried out on 8th August 2007.

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

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Hawthorn House Short Break Service Hawthorn House St Godrics Close Carr House Drive Framwellgate Moor Durham DH1 5PJ Lead Inspector Mr Stephen Ellis Unannounced Inspection 8th August 2007 10:15 Hawthorn House Short Break Service DS0000070005.V346945.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 Short Break Service DS0000070005.V346945.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 Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorn House Short Break Service Address 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) Hawthorn House St Godrics Close Carr House Drive Framwellgate Moor Durham DH1 5PJ 0191 3835151 www.durham.gov.uk Durham County Council Catherine Duggan Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following category: 2. Learning Disability - Code LD, maximum number of places: 10 The maximum number of service users who can be accommodated is: 10 4th August 2006 Date of last inspection Brief Description of the Service: Hawthorn house is registered to provide care (but not nursing care) for 10 people with learning disabilities between the ages of 18 and 65 years (8 beds for respite care and 2 beds for urgent/emergency admissions). It provides a respite (short term break) service only, for people who usually live at home with their parents. During their stays, clients tend not to go to their usual day services/activities as the home aims to make the visit more like a holiday, with regular trips out. The home is a high quality, purpose-built, single-storey, detached building, with large grounds, on the outskirts of Durham. It is situated on the edge of a large housing estate and has good links with the local community. All the bedrooms are spacious singles, each with en suite facilities. There are comfortable lounge/dining areas, plus a multi-sensory room, and a large reception/office area at the front. Durham County Council (Adult and Community Services) provide the service. There are good road links to the building and good car parking available to the front. The daily charge for the service is £149.96 (includes an overnight stay) and the weekly charge is £1049.71. Some financial assistance with these charges may be possible, depending upon individual circumstances. There are no other fees or charges payable for the service provided, including costs incurred in activities. Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over 5 hours. It included a tour of the building, examination of key records, plus discussions with service users and staff. Comments were received from 12 service users, 4 relatives and 6 staff. Service user questionnaires were used in the course of this inspection and reference has been made to Durham County Council’s independent evaluation report of the short break service provided at Hawthorn House (April 2006). What the service does well: The overall quality rating for this service is excellent. This judgement has been made using available evidence including a visit to this service. Service users and relatives have consistently reported high levels of satisfaction with the service provided by Hawthorn House. The service moved to purpose built premises in April 2007 and environmental standards are very impressive. Typical comments from relatives quoted in Durham County Council’s independent report: ‘Short Break Service Evaluation 2006’ (April 2006), concerning the overall satisfaction with the service at Hawthorn House prior to the move, included: “Staff and care are excellent…My daughter has always been happy to go to Hawthorn House. The staff make a fuss over her and she is always very happy and content there which is very important. I am happy to leave her there knowing she is safe…Hawthorn House suits my son’s needs excellently. He is always happy to go which pleases me. I have no complaints at all. In an emergency they will always try to accommodate your needs.” Typical comments from service users and their representatives during the current inspection included: “I am X’s Dad and the people I have met at Hawthorn House are always polite, respectful and courteous…I like it here, the staff are very nice and help you do things, like go to Durham and buy things that you want at the shops…the food’s good here, you can have what you like… I like coming here because it’s nice and friendly and there are different things to do.” Hawthorn House Short Break Service DS0000070005.V346945.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. The summary of this inspection report can be made available in other formats on request. Hawthorn House Short Break Service DS0000070005.V346945.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 Short Break Service DS0000070005.V346945.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): 1 and 2. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Prospective service users and their representatives have the information needed to choose a short break service that will meet their needs. The individual needs and aspirations of prospective service users are carefully assessed. EVIDENCE: Most service users and/or relatives who were consulted said that they had full information from which to make decisions concerning the service at Hawthorn House. As one relative said: “X already knows about Hawthorn House from previous visits and had been informed it had moved premises”. The home has a very clear service user guide with pictorial representations of key information. This and other helpful information (such as the home’s Short Break Newsletter) is readily available in Reception for prospective service users and their representatives. Documentary evidence in care plans, personal profiles and assessments of need showed that prospective service users’ needs and aspirations are carefully recorded and assessed prior to admission. Comments received from relatives and staff confirmed that the service has a good understanding of service users’ needs and aspirations. Local Authority Care Managers are involved in the commissioning of respite care at Hawthorn House and, increasingly, in person centred planning with individual service users who visit Hawthorn House for short breaks. Good communication between Care Managers, relatives and staff was evident (e.g. correspondence, reviews and comments received from relatives and staff). Typical comments from relatives quoted in Durham County Council’s independent report: ‘Short Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 9 Break Service Evaluation 2006’ (published April 2006), concerning the overall satisfaction with the service at Hawthorn House, included: “Staff and care are excellent”. “My daughter has always been happy to go to Hawthorn House. The staff make a fuss over her and she is always very happy and content there which is very important. I am happy to leave her there knowing she is safe.” “Hawthorn House suits my son’s needs excellently. He is always happy to go which pleases me. I have no complaints at all. In an emergency they will always try to accommodate your needs.” Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 10 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): 6, 7 and 9. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported to make choices and take responsible risks as part of an independent lifestyle. They know that their changing needs and personal goals are understood and respected by all staff involved in their care. EVIDENCE: Written assessments of need, risk assessments, care plans, personal profiles and diet sheets for individual service users confirmed that service users’ needs and choices are well documented. Comments received from service users, relatives and staff demonstrated a good understanding of, and respect for, service users’ individual needs and choices in daily life at Hawthorn House. Service user meetings are held each week and pictorial representations of issues are used to aid communication, both in discussion and in the minutes. Service users do not reside permanently at Hawthorn House, but use it for short breaks. It is not the lead agency for person centred planning, but is an important contributor. It communicates very well with other significant people/agencies involved with service users, as confirmed from correspondence seen (e.g. Local Authority Care Managers) and comments received from relatives. There are bi-monthly parent/carers’ meetings held, with invitations to a local Carers’ Support group and Learning Disability team, Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 11 to send representatives. Service users and relatives expressed confidence in the service respecting their individuality and preferences (such as meals, activities, clothing, times of retiring and rising from bed). Typical comments included: “I am X’s Dad and the people I have met at Hawthorn House are always polite, respectful and courteous…I like it here, the staff are very nice and help you do things, like go to Durham and buy things that you want at the shops…the food’s good here, you can have what you like.” Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 12 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): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users enjoy fulfilling lifestyles that reflect personal choice and are culturally appropriate for the individual. They include appropriate activities, links with local communities, interpersonal relationships, healthy diet and enjoyable mealtimes, and a balance of individual rights and responsibilities. EVIDENCE: Service users, relatives and staff described lifestyles that were satisfying and varied for service users, reflecting their needs and choices. All service users who were able to express a view said they liked coming to Hawthorn House, because it was friendly with good staff, good food and it was nice to meet up with other service users. They also liked taking part in various activities, such as visits out to local places of interest. Staff confirmed that service users participated in a wide range of social and recreational activities, depending upon their interests, wishes and needs, including shopping trips, visits to leisure centres, board/floor puzzles and games, arts and crafts, seasonal events (for example, barbecues and celebrations such as Halloween and Christmas), television, DVD films, occasional meals out, and pool. Each Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 13 bedroom has a television, CD and DVD player and service users may borrow DVDs and talking books from the local library. The home has a well-equipped, multi-sensory room that service users can use and enjoy, depending on their needs and interests. There are attractive lounges (including a quiet room) and dining room that provide a choice of communal space for socialising, shared or personal activities and meals. Good links with the community were developing, including contacts with a local school, neighbours and local shops and facilities, such as library. A typical comment from a service user was “I like coming here because it’s nice and friendly and there are different things to do.” A varied menu was evident, offering a choice of wholesome, appetising meals and drinks, reflecting service users’ preferences. Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 14 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): 18, 19 and 20. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The arrangements for service users’ personal and healthcare support ensures their physical and emotional needs are addressed in ways they prefer and require. Service users are protected by the home’s policies and procedures for dealing with medicines, helping to promote independence wherever appropriate. EVIDENCE: Comments received from service users, relatives and staff confirmed documentary evidence in care plans and personal profiles of service users’ physical and emotional needs being well addressed. The personal and healthcare support provided to service users is based on comprehensive, detailed assessments of need and risk, including service users’ wishes, feelings and preferences wherever possible. There are good systems in place to help relatives, service users, staff and external health and social care agencies communicate about issues concerning service users’ personal and healthcare support. For example, the individual personal profile is developed for each service user from information provided by relatives and others prior to admission; on discharge from Hawthorn House, a summary report of what the service user has done and how they have been during their stay is sent to the relative/carer. Also, there are weekly service user meetings at Hawthorn House, plus bi-monthly meetings for relatives/carers and representatives from a local carer support group and Local Authority Learning Disability team. On Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 15 admission, service users’ personal and healthcare needs are rechecked, including the provision of prescribed medication. The vast majority of service users delegate responsibility for storing and administering their medicines to members of the care staff team who are well trained in the safe handling of medicines. Records of administration of medicines are maintained and several examples were seen. Although current arrangements are safe, it is recommended that the medicine trolley is secured by a chain to a wall or door frame inside the medicines room when not in use, and that a photograph of the service user is placed next to their record of administration, along with their name, date of birth and room number, to aid identification. Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 16 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): 22 and 23. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. People who use the service are able to express their concerns, and have access to a robust, effective complaints procedure, are protected from abuse, and have their rights protected. EVIDENCE: Comments received from service users and relatives strongly indicated that staff were approachable and welcomed feedback on how well the short break service was performing. Service users and their representatives were confident in being able to express concerns, complaints or compliments. A poster with pictorial guidance is displayed in the reception area and information is also provided in the service user guide and welcome brochure. A weekly service user meeting is held and a bi-monthly meeting with relatives and their representatives is provided, to help maximise opportunities for discussion of all issues relevant to the quality of the service being provided. Minutes are kept of such meetings and a comments book is provided. The weekly meeting format for service users is in pictorial form. The home has a robust whistle blowing procedure to allow members of staff to raise concerns about the quality of care, abuse or neglect. Staff members are well trained in all aspects of health and safety and in safeguarding adults from abuse or neglect. Staff recruitment checks are thorough and to a good standard. Staff members are well supervised and supported. The culture and value base of the service is excellent, in keeping with the Department of Health’s ‘Valuing People’ guidance. Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 17 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): 24 – 30. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The physical design and layout of the home enables people who use the service to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The new single-storey home is purpose built to a high standard and was opened in April 2007. There are 10 spacious, well-equipped, single bedrooms, all with en suite facilities (either a toilet and bathroom, or toilet, wash hand basin and shower). All are supplied with televisions, CD and DVD players. Two of the bedrooms are in a semi-independent unit for emergency admissions and, at the time of inspection, were not being used. These 2 bedrooms are supplied with en suite bathroom, ceiling hoists plus electronically operated rise and fall beds. They have their own kitchen and lounge/dining area. Four of the 8 bedrooms in the main unit are adapted for people with special needs and include electronically operated rise and fall beds, plus access to en suite bathrooms via ceiling-mounted hoists if required. A very high standard of provision is evident throughout the building. Décor and furnishings are of good quality. Communal space is provided in 2 lounges, one dining room, attractive reception area and a multi-sensory room. There is good access throughout and round the building, and the grounds are level and still undergoing landscaping. Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 18 The premises are well designed and maintained, practical and attractive. Good use has been made of natural light and sloping ceilings to create a spacious, visually stimulating, well-lit environment. There has been much consultation with service users and their representatives in the design and commissioning of the new building. The home was clean and hygienic in all of the areas inspected. Staff members are deployed in sufficient numbers to maintain a clean and hygienic environment. Staff members have undergone training in health and safety and have all the necessary equipment. Policies and procedures are well documented concerning the actions to be taken to maintain a clean and hygienic environment throughout the home. Bathrooms and toilets are supplied with liquid soap and paper towels, in wall-mounted containers. Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 19 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): 32, 34 and 35. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent, well-trained and increasingly qualified staff members, who are also well supervised and supported. The home’s recruitment policy and practices support and protect service users. EVIDENCE: Staffing arrangements are very good at Hawthorn House, as evidenced by high staffing ratios, comprehensive staff training and development programmes and excellent staff supervision and support. Staff retention is very good. Typically, there are 4 members of care staff on duty during the day for 8 service users and, at night (10 pm to 7 am), one waking member of care staff plus one member of staff on call on the premises. It is good that 6 out of 11 permanent care staff members (54 ) have achieved National Vocational Qualifications (NVQ) at level 2 or above in Promoting Independence. One more staff member is expected to register for NVQ programmes later this year. Individual staff development records are maintained along with individual staff training needs assessments. Key training has been carried out, including safe handling of medicines, moving and handling, protection of vulnerable adults, first aid, and food safety. Some staff members have had specialist training, such as communicating with people with sensory impairment, caring for people with epilepsy, and dealing with challenging behaviour. Individual staff supervision takes place with members of care staff every 8 to 10 weeks, and there is an Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 20 annual appraisal. The supervisors are the registered manager and the support manager. Supervision and appraisal is evidence-based, and include one planned observation and 2 self-reviews for each member of staff each year. Ten evidence-based standards are applied. In addition, there are monthly staff meetings; a 70 attendance is the minimum expected of staff. Staff and management felt that these arrangements worked very well and supported the aims and objectives of the organisation. Records of staff supervision, team meetings and appraisal are maintained. Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 21 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): 37, 39 and 42. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The management and administration of the service is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: Comments received from service users and their representatives confirmed a high level of overall satisfaction with the service provided by Hawthorn House. Typical comments included: “X says he is always happy at Hawthorn House but would talk to a member of staff if he was unhappy…the staff always treat me well…the home is always fresh and clean.” The report of the independent evaluation of the short break service (Durham County Council, April 2006) indicated high levels of satisfaction being expressed by carers, commissioners and focus groups with service users. Regular meetings with service users (weekly) and carers (bi-monthly) give feedback on the quality of the service being provided and encourage suggestions for improvements. One practical example of this is the intended purchase of a special, electronically operated easy chair for the lounge. The report of the 2006 evaluation has been Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 22 published and copies are available in reception, along with much other useful information, including pictorial newsletter and complaints procedure. The service has achieved various awards concerning quality, including Investor in People and Charter Mark and is working to maintain accreditation in these awards. A full programme of maintenance checks is carried out and staff training programmes address health and safety issues systematically, including fire safety and fire drills, risk assessment, moving and handling, food safety, first aid and safe handling of medicines. Social and recreational activities are varied and appropriate, designed to promote service users’ welfare and wellbeing. The registered manager is currently unavailable for duty. The Support Manager, Linda Turnbull, is operating as acting manager. She is well qualified in Social Care and Social Work and has achieved National Vocational Qualification (NVQ) level 4 in Management. She has substantial management and learning disability experience. A replacement Support Manager has been appointed. Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 23 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 4 2 4 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 4 23 4 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 4 29 4 30 4 STAFFING Standard No Score 31 X 32 4 33 X 34 4 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 3 x LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 4 X 3 X X 4 x Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 24 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 Refer to Standard YA20 Good Practice Recommendations Although current arrangements are safe, it is recommended that the medicine trolley is secured by a chain to a wall or door frame inside the medicines room when not in use, and that a photograph of the service user is placed next to their record of administration, along with their name, date of birth and room number, to aid identification. Hawthorn House Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Darlington Area Office No. 1 Hopetown Studios Brinkburn Road Darlington DL3 6DS 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 Short Break Service DS0000070005.V346945.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!