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Inspection on 26/01/06 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 26th January 2006.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

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 environment has improved significantly over the last twelve months, with all the communal areas having been refurbished. Small sitting areas have been created in the dining area and dining areas have been created in the sitting areas. New furniture carpets and curtains have been bought to improve the homely environment. Residents spoken with were positive about the staff, saying they were `kind and polite`. A new cook has been employed who provides homemade cakes and provides a choice of nutritionally balanced meals, which of the six residents spoken with five said the food was either `good or excellent`. One resident expressed their opinion that the food was `disgusting`. Clear records are maintained for staff training and staff are able to access a variety of training including NVQ level 2 and 3

What has improved since the last inspection?

With the refurbishment in the communal areas complete work has started on the bedrooms. Those bedrooms viewed were clean and bright with new bedroom furniture. Also improved from the last inspection care plan and diary notes showing what care staff have been involved in, as well as how residents are on any particular day. The new deputy manager has started carrying out regular supervision with staff and this is well documented following a standard format, which covers such areas as competency and training. Evidence was seen that there is a programme of activities for each month and staff are being given the time to spend with residents to interact and encourage different activities such as jigsaws and card games. The external grounds, which were in a very untidy state at the last inspection, were much improved. Staff records were inspected and now meet the standard and included all the documents that are needed to ensure that recruitment practice is robust. The manager also regularly informs the Commission of any incidents or accidents within the home. The Responsible Person also carries out monthly visits in accordance with the regulation 26 of the Care Homes Regulations and sends copies to the Commission.

What the care home could do better:

Although it is noted that the environment has significantly improved since the last inspection, at the beginning of January 2006 the heating system broke down and remained out of action for two days whilst it was being repaired. It is recommended that at the earliest opportunity that the heating system is replaced. It is also acknowledged that this is a significant cost that the company will need to invest to bring it up to standard and that it cannot be completed in the winter months. A number of concerns raised by relatives still do not appear to be fully resolved. It was noted that the manager has taken action several times to try to bring these matters to a conclusion but the inspector is aware that they are never fully resolved. The registered person must take action to resolve the long-standing concerns of a small group of relatives. Improvements need to be made within the medication administration, to ensure residents are not placed at risk. Procedures need to be improved to minimise the risk of medication being dropped by staff when they transport tablets in teaspoons. The registered person must enable residents to access a religious service of their choice and ensure that sufficient food is always available at each mealtime.

CARE HOMES FOR OLDER PEOPLE Hawthorn Lodge Care Home Beckhampton Road Bestwood Park Nottingham NG5 5LF Lead Inspector Susan Lewis Announced Inspection 26th January 2006 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.V271834.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 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.V271834.R01.S.doc Version 5.1 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 Regal Care Homes Ltd Gemma Else 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.V271834.R01.S.doc Version 5.1 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 24th June 2005 Date of last inspection Brief Description of the Service: Hawthorn Lodge is a large home that was previously owned by the Local Authority. The home is 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 dining rooms. Some of the bedrooms are ensuite. There is a passenger lift to the first floor. The home is set in its own grounds in a residential area with easy access to shops and bus routes. Regal Care Ltd bought the company in August 2004 and have begun a major refurbishment programme that will see all the communal areas redecorated, along with the residents bedrooms. This work started on 9th May 2005, the majority of the communal areas have now been refurbished and there is an ongoing programme of refurbishing the bedrooms. Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was the third inspection carried out in the inspection year and was announced. One inspector carried it out over the course of nine hours. A partial tour of the building was carried out and staff and care records were inspected. Four staff, six residents and five visitors were spoken with during the course of the inspection. The inspector had also received several complaints shortly before the inspection and these areas were addressed during the inspection process. What the service does well: What has improved since the last inspection? With the refurbishment in the communal areas complete work has started on the bedrooms. Those bedrooms viewed were clean and bright with new bedroom furniture. Also improved from the last inspection care plan and diary notes showing what care staff have been involved in, as well as how residents are on any particular day. The new deputy manager has started carrying out regular supervision with staff and this is well documented following a standard format, which covers such areas as competency and training. Evidence was seen that there is a programme of activities for each month and staff are being given the time to spend with residents to interact and encourage different activities such as jigsaws and card games. The external grounds, which were in a very untidy state at the last inspection, were much improved. Staff records were inspected and now meet the standard and included all the documents that are needed to ensure that recruitment practice is robust. The manager also regularly informs the Commission of any incidents or accidents within the home. The Responsible Person also carries out monthly visits in accordance with the regulation 26 of the Care Homes Regulations and sends copies to the Commission. Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 6 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 Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5 Prospective residents are assessed and can be assured that their needs will be met. EVIDENCE: Three care plans in total were viewed for the purpose of this inspection. All plans viewed had a copy of the social worker assessment and a copy of the homes own assessment. This covered all aspects of the activities of daily living. An immediate requirement was left at the last inspection to ensure that all residents had a prepared written plan. From those plans viewed at random evidence was seen that this requirement is now met. The daily diary notes provided evidence of what care staff were providing to meet the needs of residents. Staff spoken with understood the needs of the residents they worked with including where residents had dementia, they understood the how to ensure residents could make choices and supported them accordingly. One care plan viewed was for a resident who had been placed on respite as an emergency admission. The care plan had been completed within three days of the person arriving all support was detailed. Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Care plans are now regularly reviewed. Residents are placed at potential risk by their health needs not being met. EVIDENCE: An immediate requirement was left at the last inspection to ensure that residents care plans are kept under review; evidence was seen that this is taking place at regular intervals and where possible relatives and residents are involved. Relatives spoken with confirmed that they were involved. Plans are set out in detail and cover all aspects of the residents’ daily life both their personal and health care needs. As part of the complaint received one resident whose care was followed through by viewing the care plan and speaking to staff, relatives and resident had a number of care needs that were documented. Staff spoken with were aware of the individuals care needs, these were documented and even reinforced by a notice placed in the diary notes. However, from evidence provided by the relative, the resident’s care needs were regularly failing to be met by staff. The resident confirmed that staff had forgotten on a number of occasions to provide care according to the care plan although on the day of the inspection the resident confirmed she had received all her care during the last few days. In discussion with the registered manager she confirmed staff had been reminded to meet resident’s care needs and had taken further action Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 10 where it had been necessary. This appears to be an ongoing concern and the manager must ensure that staff provide care as detailed in care plans. Care plans provided evidence that residents were supported to access other healthcare professional services such as the chiropodist and optician. Where residents had continence needs, advice was sought from the district nurse and residents with pressure care needs the district nurse visited to dress these areas. A requirement was made at the last inspection to ensure that the fridge in the medication room was regularly defrosted to ensure it would close. Evidence was seen that this has been met. Medications for those residents whose care was being tracked was looked at and was recorded appropriately. However there were two areas of concern. The first being the staff who was administering the medication was doing so by popping the blister pack the medication came in onto a teaspoon then walking over to the resident to give it to administer. There is a risk that the staff member could be knocked and drop the medication on the floor. The registered person must ensure that procedures for administering medication follow guidance given by the Royal Pharmaceutical Society. Staff spoken with confirmed that they had either received or were about to receive medication training. The second area of concern is regarding the covert administration of medication. Evidence was seen that the manager had sought permission from the GP to provide medication in a covert manner to a particular resident. The registered person is strongly recommended to follow the advice given by the UKCC this can be found on their website, www.ukcc.co. This ensures that all parties involved including the doctor, the relative and the community pharmacist are involved in any decision around covert medication and minimises the risk of this becoming routine institutional practice particularly where residents may lack capacity. It is also strongly recommended that where staff hand write medication information on Medication Administration Record sheets that these are signed and countersigned to confirm that they are correct to minimise the risk of error. Residents spoken with were positive in their praise of staff saying they were very kind and nice. Residents confirmed that they only wore their own clothes and staff spoken with understood how to maintain residents’ privacy and dignity. Residents spoken with said ‘staff always knock on my door’. ‘When I have a bath they always make sure I am safe and covered up’. However one resident said although staff knock they do not always wait before entering. This has lead to the individual being disturbed when with a visitor. Relatives spoken with said that they felt happy with the privacy and respect their relative received. However a relative spoken with raised concern over the fact that resident no longer had access to a private phone and had to use the office line. Residents spoken with who used the phone occasionally said they felt uncomfortable using the office phone as they felt they were holding staff up from doing their job. The manager said that the home has two lines coming in and it wouldn’t create problems if residents were to be in the phone. It is still recommended that residents have access to a phone that is private and away from the office as currently residents feel inhibited when making and receiving calls. Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 14 and 15 Residents are provided with well organised activities and nutritious wholesome meals. The manager must ensure that enough food is provided at all times for residents. EVIDENCE: On the day of the inspection a programme of activities was on display and staff were seen encouraging residents to take part in a variety of activities including jigsaws, music, and netball. Four out of the five relatives spoken with said that they felt they were improvements in the type and number of activities offered to residents. Five out of the six residents spoken with said that they appreciated and enjoyed the activities; the sixth resident did not feel there were any activities put on for residents to be involved in. Residents meetings are held, however only a very few residents participate; relatives are also encouraged to attend. However relatives spoken with were not always aware these meetings were taking place. Relatives spoken with said that they were concerned that no religious observance had been arranged for those who would like to attend. Although evidence was seen to show that residents are involved in care plan reviews, residents spoken with were not always sure what their care plan was or how to access it. A recommendation was made at the last inspection to remind residents that they can access their files at any time. The registered Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 12 manager is reminded that she must continue to ensure residents are aware of their rights. The home employed a new cook during last year and she is qualified and knowledgeable with regards dietary needs of older people. On the day of the inspection the food was not sampled but it appeared appetising. Five out of the six residents spoken with said they felt the food was very tasty and enjoyed the choice. One resident said ‘you can’t beat the food’. ‘The cook does some lovely meals’. Residents also described the cook as ‘lovely’; the cook was seen during meal times walking round and talking to residents and checking they were happy with the meals. Only one resident expressed any dissatisfaction with the food, describing it has ‘disgusting’. However four out of the five relatives spoken with all said that the food looked appetising and that their loved one enjoyed the food. Evidence was also seen that residents had increased in weight, showing that they were receiving nutritious food. It was evident however that the home did not have a grill and therefore was unable to provide certain rudimentary meals such as cheese on toast. It was recommended that a grill be provided. The Responsible Person from Regal Care Ltd made arrangements during the inspection for a grill to be purchased. The kitchen was well ordered with plenty of fresh fruit and vegetables available for residents. One visitor spoken with said that there was always bowls of fresh fruit available and jugs of juice have now been made available. However during the evening meal there appeared not to have been enough food made for residents. Staff on duty in the dining room at the time were spoken with and confirmed that this was not the first time there had been insufficient food for a meal. The registered person must ensure that sufficient food is available at all times for residents. Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Residents are placed at potential risk where complaints are not being resolved satisfactorily and the outcome is that their care is not being provided as detailed in their care plan. Residents are protected from abuse by the policies and procedures within the home. EVIDENCE: The complaints received prior to the inspection were. 1.Failure to meet specified healthcare needs as detailed in residents care plan. The manager had investigated this and had found it substantiated and took action. However the matter had reoccurred and the relative did not feel confident that staff were able to meet their loved ones needs. Evidence was seen that the manager had taken various action to minimise this happening again unfortunately staff were still falling short of their duty of care. The registered person must ensure staff are competent to carry out their duties. 2.The heating had been out of action for a considerable period over New Year. At the time this occurred the manager provided the Commission with written evidence to show that all remedial action had been taken including the final solution if the heating was not repaired to transfer residents to another home. Although the heating was out of action the manager reacted as promptly as she could and residents were provided with extra blankets, hot drinks and electric heaters to minimise the risk. All that could be done was done. Residents spoken with said that they felt if they needed to complain they were Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 14 able to complain to the manager. Some relatives spoken with said they felt confident that the manager would deal with any concerns if that they needed to make any known, however a number of relatives who had raised concerns said that they felt they had made the same complaint several times and things had not improved, this was causing a great deal of anxiety for relatives who felt concerned at leaving their loved one at the home. When complaints have come via the Commission and been passed through to the organisation to follow up, they have always been looked at within twenty-eight days as per their complaints procedure and have provided evidence of how the matter is to be dealt with and whether the complaint is substantiated. The evidence obtained during the course of the inspection was split between those who had raised concerns with the manager and did not feel things had improved and those who had had no concerns to raise. The registered person must ensure that where complaints of a similar nature are happening that appropriate action is taken to minimise risk to residents. The information regarding how to make a complaint had been taken down during redecoration and not been replaced. The registered person must ensure the home displays information for people to be able to access the complaints procedure. Residents spoke with said they felt safe and that staff were kind and ‘you can’t beat them’, ‘they’re lovely’. Staff spoken with had a good understanding of what constituted abuse and knew exactly what to do if they suspected it, including a good understanding of the whistle blowing policy. A copy of Nottingham Protection of Vulnerable Adults procedures is available in the office to ensure that if abuse is suspected the staff know exactly what to do and who to inform. Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24 and 26 Residents are provided with a pleasant and homely environment. EVIDENCE: Significant improvements have been made over the last few months to the environment. The communal areas are now bright and cheerful with new furniture having been purchased for both the lounge areas and the dining room. The exposed brick has been plastered over to minimise the risk to residents of skin abrasions should they fall against the brick. New carpets have also been bought throughout the home. The grounds, which at the last inspection were in a very unkempt state, have been tidied, thereby meeting a requirement made at the last inspection. Relatives and residents spoken with all felt that the home’s décor was much improved. There is ample communal space for residents and residents can choose to eat in a variety of locations throughout the home including their bedrooms and the reception area. There are toilet facilities near the dining room and lounges. The shower is currently undergoing renovation, but this is taking some time due to plumbing limitations. This has caused some difficulty for residents who Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 16 want a shower rather than a bath. All bedrooms are either ensuite or have a sink. Throughout the home there are handrails and aids and adaptations suitable to meet the needs of the residents. There is a shaft lift to the first floor and all bedrooms have a call system. Of the selection of bedrooms viewed they were bright and pleasantly decorated with recently bought furniture. Residents spoken with were not sure if they could have a key. The registered person must ensure that all residents are provided with a key unless their risk assessment suggests otherwise. All residents spoken with said that they were happy with their bedroom. The lighting and furniture are domestic in character. The heating can be controlled in residents’ bedrooms. During the New Year the pump to the boiler broke down causing a number of complaints to be made. The registered person made suitable arrangements whilst the boiler was being repaired to minimise the risk to residents. The registered person is aware that the heating system will need a major overall in the near future due to its age. As this effectively means the system will be out of action whilst a new system is put in place this can only take place in the summer months. On the day of the inspection the home was clean and odour free. Residents and relatives spoken with confirmed that the home was now kept clean and the issues around the odour in the home appeared to have been resolved with the purchase of new carpets. The laundry was not fully inspected during this visit. Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 There are sufficient trained and experienced staff on duty to meet the needs of residents. Recruitment procedures are in place to protect residents. EVIDENCE: A requirement had been made at the last inspection to ensure that enough staff were on duty at any time. From evidence provided with the pre inspection information, rotas showed that there were enough staff on duty to meet the needs of the residents. This requirement is now met. Relatives spoken with said that although there were staff available they were very busy. Residents said that ‘staff are there if you need them’. Staff spoken with had a variety of experience and training in understanding the needs of the residents. Evidence was seen that staff were able to attend a variety of courses including NVQ level2. Three staff files were inspected and were complete with two references and Criminal Records Bureau checks. A requirement had been made at the last inspection regarding staff files. This requirement is now met. Staff files provided evidence that induction and mandatory training is being carried out Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 36 and 38 Residents and staff health and safety is maintained by working practices within the home. EVIDENCE: Evidence was seen that staff received regular structured supervision, staff spoken with said they found this valuable. Staff confirmed that they received mandatory training to support the health and safety of the residents and themselves. A requirement was set at the last inspection regarding risk assessing where a resident had had an accident. Evidence was seen that the manager carries out detailed risk assessments of safe working practices within the home. This requirement is now met. All incidents are reported to the relevant body to ensure that the home is run in a safe manner and risks to staff and residents are minimised. Evidence was seen that equipment is maintained and fire tests are carried out regularly. Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 1 9 1 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 2 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 3 X 3 Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 Requirement The Registered Person must make arrangements for the safe handling and administration of medication received into the care home. Medication should not be distributed on a teaspoon. The Registered Person shall ensure that so far as practicable service users have the opportunity to attend religious services of their choice. The Registered Person shall provide in adequate quantities, suitable, wholesome and nutritious food, which is varied and properly prepared and available at such times as may be reasonably be required by service users. The Registered Person must ensure that all residents and visitors are aware of how to make a complaint. The Registered Person shall ensure that the care home is conducted in such a manner, which respects the privacy and dignity of service users. All service users must receive a key to their bedrooms unless their risk assessment suggests otherwise. DS0000061999.V271834.R01.S.doc Timescale for action 28/02/06 2 OP12 16 01/04/06 3 OP15 16 21/02/06 4. OP16 22 01/03/06 4. OP24 12 01/03/06 Hawthorn Lodge Care Home Version 5.1 Page 21 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 OP9 Good Practice Recommendations The manager should follow the UKCC position statement on the covert administration of medicines- Disguising medicine in food and drink. To be accessed at www.ukcc.com. The manager should review administration of medication practices to minimise the risk of dropped medication. The manager should ensure staff sign and countersign hand written Medication Administration Record sheets. The manager should ensure that residents have access to a separate telephone from the one in the main office. The manager should purchase a grill to ensure that residents are able to have a full choice of food. 2. 3. 4. 5. OP9 OP9 OP10 OP15 Hawthorn Lodge Care Home DS0000061999.V271834.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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. 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