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Inspection on 17/04/07 for Hawthorn Lodge Care Home

Also see our care home review for Hawthorn Lodge Care Home for more information

This inspection was carried out on 17th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The meal was observed and it was appetising and nutritious, residents spoken with said they enjoyed the meals and had plenty to eat. Residents are given alternatives to the two hot choices. A range of organised activities are available in the afternoon for those residents who wish to participate. Staff continue to be able to access a variety of training and clear records of training are maintainedThe enclosed garden is pleasant and provides residents with access to fresh air and somewhere to sit in the warm weather.

What has improved since the last inspection?

Most residents` plans are reviewed regularly and where possible either the resident or families are involved in their creation. Staff monitor residents who are at risk of developing pressure sores. A system has now been set up to record residents medication when they leave the building for any reason to ensure that they either have it with them or it is given to them at an appropriate time. Organised activities have improved for residents with staff organising different things within the home to ensure residents are provided with some stimulation for at least part of the day. The enclosed garden to the front of the home is significantly improved from the last inspection enabling residents to access a pleasant garden. Care plans show that residents are risk assessed as to their ability to hold a key and where unable or they do not wish to it states on the care plan that bedroom doors are to be locked ensuring residents privacy.

What the care home could do better:

Improvements must be made in the policy and procedures for storage and administration of medication to ensure residents are not placed at risk. Residents` privacy and dignity is not supported or maintained and the responsible person must ensure that staff understand the importance of this how it must be undertaken. Although organised activities take place residents are not routinely encouraged to be involved in the general day to day tasks of the home and staff do not spend time just talking to residents. Residents and relatives should be made aware of the complaints procedure and staff need to understand how to support all residents to make a complaint and protect them from potential abuse. Improvements in the environment need to be made including continuing to decorate the bedrooms and maintain the communal areas.Staff must understand the need to follow infection control policies to minimise the risk to themselves and residents. The laundry door must be kept shut when staff are not in attendance to minimise risks to residents. Staff must only be confirmed in post after a Criminal Records Bureau check has been carried out of that a POVA First check carried out and the member of staff works under close supervision. The quality assurance survey must be used to inform improvements within the service and show that it is being run in the best interests of residents. Staff deployment should be looked at in light of the number of falls residents experience.

CARE HOMES FOR OLDER PEOPLE Hawthorn Lodge Care Home Beckhampton Road Bestwood Park Nottingham NG5 5LF Lead Inspector Susan Lewis Key Unannounced Inspection 17th & 18th April 2007 10:00 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 Hawthorn Lodge Care Home DS0000061999.V335067.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. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorn Lodge Care Home Address Beckhampton Road Bestwood Park Nottingham NG5 5LF 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) 0115 967 6735 0115 967 1815 www.regalhomes.com Regal Care Homes Ltd Manager post vacant Care Home 60 Category(ies) of Dementia - over 65 years of age (30), Old age, registration, with number not falling within any other category (60) of places Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Within the total number of beds, a maximum of 30 may be used for the category DE(E) Within the total number of beds, a maximum of 60 may be used for the category OP 11th October 2006 Date of last inspection Brief Description of the Service: The home fees are £350-360. A copy of the most up to date report is found in both the manager’s office or the senior carers’ office. Hawthorn Lodge is a large home registered to provide personal care for up to 60 older people. It has several lounges and one large dining room as well as eating areas in some of the lounges. Some of the bedrooms are ensuite. There is a passenger lift to the first floor. The home is set in its own grounds with a pleasant enclosed garden that residents have access to. It is in a residential area with easy access to shops and bus routes. There are hoists available for residents who require hoisting and there are suitable bath and shower facilities available for residents who need assistance with bathing. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for residents and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting residents and tracking the care they received through looking at their records and observing staff that provide their care. Two hours were spent observing the care given to a small group of people. All observations were followed up by discussions with staff and examination of records. The inspection was unannounced and took place over 14 hours Tuesday and Wednesday in April 2007, and was conducted by one inspector as part of the annual inspection process. A partial tour of the building took place and a selection of residents’ bedrooms was inspected. In addition, other information supplied by the provider regarding the service has been used to form judgements, plus completed surveys from residents. Other information used to inform this report was accident and incident reports received since the last inspection as well as the previous inspection report. What the service does well: The meal was observed and it was appetising and nutritious, residents spoken with said they enjoyed the meals and had plenty to eat. Residents are given alternatives to the two hot choices. A range of organised activities are available in the afternoon for those residents who wish to participate. Staff continue to be able to access a variety of training and clear records of training are maintained Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 6 The enclosed garden is pleasant and provides residents with access to fresh air and somewhere to sit in the warm weather. What has improved since the last inspection? What they could do better: Improvements must be made in the policy and procedures for storage and administration of medication to ensure residents are not placed at risk. Residents’ privacy and dignity is not supported or maintained and the responsible person must ensure that staff understand the importance of this how it must be undertaken. Although organised activities take place residents are not routinely encouraged to be involved in the general day to day tasks of the home and staff do not spend time just talking to residents. Residents and relatives should be made aware of the complaints procedure and staff need to understand how to support all residents to make a complaint and protect them from potential abuse. Improvements in the environment need to be made including continuing to decorate the bedrooms and maintain the communal areas. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 7 Staff must understand the need to follow infection control policies to minimise the risk to themselves and residents. The laundry door must be kept shut when staff are not in attendance to minimise risks to residents. Staff must only be confirmed in post after a Criminal Records Bureau check has been carried out of that a POVA First check carried out and the member of staff works under close supervision. The quality assurance survey must be used to inform improvements within the service and show that it is being run in the best interests of residents. Staff deployment should be looked at in light of the number of falls residents experience. 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 Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 8 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 Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6 Quality in this outcome area is good. Residents are assured that their needs will be met prior to moving to the home. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Five care plans were viewed with three inspected in depth as part of this inspection. All care plans had copies of the homes pre admission assessment and where appropriate a copy of the social services assessment. The assessment informed the care plan and it a plan was produced from the needs identified. This ensures that residents’ needs are met. The home does not provide intermediate care. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. Residents have their social personal and health care needs set out in a care plan however their health care needs are not always met through poor procedures for medication, and their privacy and dignity is not always respected This judgement has been made using available evidence including a visit to this service. EVIDENCE: The care plans viewed showed that residents had their needs assessed and how these were to be met by staff. In discussion with staff it was clear that they were aware of residents needs and how to meet them. Care plans provided information and evidence that residents’ needs were being reviewed regularly. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 11 During the observation period of two hours staff were observed with residents providing care according to their plans. From information seen in care plans and diary notes residents health care needs were being met and where residents were at risk of developing pressure areas they were being regularly monitored. During the inspection the medication for the month was delivered. It had been delivered still in the boxes instead of the usual practice of it Medication Dosage Systems (MDS). This meant that the medication for all the residents was contained in two trolleys and was not in any particular order. As a result it was impossible to carry out a clear audit of residents medication. The Medication Administration Record Sheet (MARS) had not been signed to indicate what medication had been delivered and what had not. One resident had been signed on the MAR sheet to say that they had been given a particular medication however this medication could not be found and the senior carer who administered the medication informed the inspector that the medication administered had been taken from the ‘returns’ box. This is poor practice and potentially places residents of risk from not receiving their medication as prescribed. An immediate requirement was left with a representative of Regal Care to ensure that systems were in place to minimise the risk to residents. During the course of the inspection staff were seen to speak respectfully to residents. However one carer was witnessed standing outside a toilet and calling to the senior carer ‘He’s wet and I need trousers and pants-I got a pad from the cupboard’. The staff member continued to have a number of loud exchanges regarding the resident asking for help to ‘sort him out’. Residents’ privacy and dignity are not supported by this behaviour. During the observation a resident was observed to wearing a short-sleeved blouse, however the care plan specifically mentioned that they preferred to wear long sleeved shirts. This does not support the resident’s dignity Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. The lifestyle within the home does not always satisfy the residents’ social and recreational needs. Residents are supported to make choices and nutritional and wholesome meals are given in a pleasant dining room This judgement has been made using available evidence including a visit to this service. EVIDENCE: The observation period took place between 10.35am and 12.35pm; residents spent much of their time unoccupied or asleep. When staff did interact with resident it was often very focussed around a task such as going to the toilet or transferring from chair to wheelchair. Generally there was little positive interaction that would improve the well being of the resident. In discussion with the acting manager she said that activities took place in the afternoon, however this is purely organised activities such as games and art, staff are not encouraged to sit and read a paper or involve residents in the day Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 13 to day activities such as cleaning, tidying and other daily routines that they may have the skills, interest and abilities to do. Some residents spoken with said that they did have trips out in the warmer weather and that they had ‘ a bit of a do’ such as concerts. From residents questionnaires a response was that more could be done in the way of things for residents to do. Having activities that are appropriate to the needs and abilities of the residents ensures that they maintain their skills and improves their level of well being within the home. Evidence was seen on care plans that residents spiritual needs were assessed and in discussion with residents they confirmed that a local priest visited the home to take services and speak to residents. Visitors were seen during the day and were welcomed by staff. A variety of lounge space is available to enable residents to see their visitors in private if they so wish. The mid day meal was observed and a choice was given to residents regarding where they ate and what they wanted to eat. Staff were observed providing assistance to residents who needed it, to eat their meal. Staff spoken with said that the cook does the menu planning after talking with residents. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate. Although there is a complaints policy residents and relatives are not always aware of it and staff do not support residents to make a complaint. Systems are in place to protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: During December 2006 and January 2007 the Commission received several complaints regarding the heating system failing. The heating system failed at the same time the previous year. Although the acting manager took action to minimise risk to residents obtaining heaters and water heaters, residents’ well-being was placed at risk by this incident taking place. The Commission wrote to Regal Care Ltd and asked for a date when the heating system is to be replaced. A date of May 2007 was given. This will be monitored to ensure the improvements are made. Evidence was seen that records are kept of complaints and are responded to within timescales according to the homes policy. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 15 There is a complaints policy, copies of which are displayed in the reception area and are available in the manager’s office. However in resident surveys returned to the Commission as part of the pre inspection information not all residents and relatives are aware of this policy. This means not everyone is aware of how to make a complaint about the service. In discussion with staff when asked how would you support a resident who had dementia to make a complaint the member of staff replied that ‘as you can’t always believe them when they have dementia it is difficult to do anything’. This does not ensure residents are supported to make complaints and protect them from potential abuse. An adult protection referral was made regarding an incident that took place earlier in January 2007. Copies of the minutes of the meeting called by social services were passed to the Commission and showed that the management followed procedures and acted appropriately therefore there was no further action necessary from the home. In discussion with staff they were aware of whistle blowing policies within the home and were aware of what constituted abuse and what they must do to protect residents. Staff have had training on abuse awareness. Residents’ money is held in safe place with records that show income and expenditure. Residents are protected from financial abuse. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and26 Quality in this outcome area is adequate. The home is looking shabby but ongoing refurbishment is planned to maintain the home. Infection control policies are not always adhered to protect residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Although a great deal of refurbishment work has taken place since Regal care took over the running of the home the communal areas are beginning to look tired and shabby particularly around door edges where wheelchairs have knocked the walls and frames. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 17 Some resident bedrooms are also looking shabby with furniture looking very tatty and the veneer peeling from the edges. A comment received from a relative on the Have your Say forms was that their ‘relatives bedroom needed redecorating and that the furniture was old’. This means residents are not living in the most comfortable environment to support their needs. Evidence was seen in a report provided by Regal Care of planned expenditure for the renewal of the fabric of the home over the next 12 months. There is a maintenance man and staff spoken with said that when things go wrong he responds promptly to repair it. The enclosed garden area to the front of the home was pleasant and provided residents with access to the outdoors where they could sit if they so wished. A small green house had been provided for residents who wanted to sow seeds and potter in the garden. During the day a soiled continence pad was seen on the corridor near the toilets. A member of staff was asked to clear it away and did so without using gloves and not following infection control measures. The laundry facilities are adequate however the doors are left open and unattended and there is potential risk to residents as the home is registered for people with dementia. The kitchen was clean and appropriate action was taken to minimise risks to residents by following good infection control measures records were seen of fridge and freezer temperatures being taken and records taken to show what temperature the meals were served at. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. Although staff receive training and are employed in sufficient numbers residents are placed at risk by inadequate recruitment practice. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff spoken with said that they felt that everyone had a clear idea of what was expected of them what their job is, always receive a handover at the end of each shift as well as write the dairy notes of the days events and care. Staff did comment that it does feel that there is enough staff on but due to the high dependency of some residents it can take longer sometimes at peak times such as morning and it can feel very rushed and busy. Staff said that access to training is not a problem and they are supported to do their NVQ. There are currently 5 staff with NVQ 2 and 8 currently undertaking training out of 29 staff, this information was provided by the acting manager from staff records. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 19 Staff confirmed that when they applied for the job at the home they had to fill out an application and a Criminal Records Bureau application before starting work. Staff spoken with commented that ‘There are a lot of falls and it may be that residents are wrongly placed, we have had OT to do assessments but have lots of residents with high needs’. ‘Where staff’s first language is not English it can cause problems for residents who have dementia’. Comments received back on ‘Have your say’ forms say that some staff are better than others but overall not bad. Evidence through the observation was that there was plenty of staff in the communal areas to meet the needs of those residents in that area. However due to the level of falls the acting manager may wish to look at the deployment of staff to ensure the safety of all residents. Staff files were viewed and although the recruitment process appeared good some staff files viewed did not have evidence of Criminal Records Bureau or POVA First checks in place before the person started work. This places residents at risk where unsuitable people may be employed to work with vulnerable adults prior to suitable police checks taking place. Records of training seen showed that staff had received a wide variety of training including all mandatory training Skills for Care induction. This ensures staff have the skills and knowledge to work with residents to meet their needs. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is adequate. Systems are in place to ensure the health and safety of residents and staff, it is not always clear that the home is run in the best interests of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: There is currently no registered manager and a warning letter was sent to Regal care as they operating a home without a registered manager. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 21 A response was received from the responsible individual and the acting manager has made an application to be registered therefore no further action will be taken at this time. Although there is a quality assurance questionnaire this information is not yet collated and currently does not inform development within the home. Therefore the responsible individual cannot be assured that the service that is provided is meeting residents’ needs and that they think it is good quality. Residents money is appropriately stored staff were observed asking for money from the safe to purchase items for them and in some cases taking the resident with them to do the shopping. The records are signed by staff to indicate they have taken the money and for what purpose. This ensures residents are free from financial abuse. The acting manager informs the Commission of all incidents within the home that effect the residents well being. Ensuring that appropriate action is taken to minimise future risk. Accident records were looked at and there appeared to be a high number for a particular resident. This was raised with the manager who said that this had been passed to the doctor and the resident was taken to hospital. Records were seen to show that regular fire tests are carried out, as are other health and safety tests. This ensures that residents and staff live and work in a safe environment. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 1 10 1 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 2 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 2 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 2 X 2 X 3 X X 3 Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 23 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. 1. Standard OP9 Regulation 13(2) Requirement Arrangements must be made for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home to ensure resident health needs are managed appropriately. Residents must be treated with dignity and their privacy supported. Care must be provided in such a way as to maintain dignity and respect residents’ wishes. Residents choices and wishes must be taken into consideration when arranging activities to ensure their health and welfare is met. Residents and relatives must be made aware of the complaints procedure Staff must be aware of and follow the infection control policy and procedures particularly when handling soiled incontinence pads. Information received from the quality review must be used to help improve the service and the DS0000061999.V335067.R01.S.doc Timescale for action 19/04/07 2 OP10 12(4)(a) 01/06/07 3 OP13 12(2)(3) 01/06/07 4 5 OP16 OP26 22(5) 13(3) 01/06/07 01/06/07 6 OP33 24(1)(b) 01/08/07 Hawthorn Lodge Care Home Version 5.2 Page 24 results of the survey supplied to the Commission and to residents. 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 OP16 Good Practice Recommendations Ensure that staff understand the importance of supporting all residents in making a complaint. Hawthorn Lodge Care Home DS0000061999.V335067.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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 Lodge Care Home DS0000061999.V335067.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. 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