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Inspection on 27/04/06 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 27th April 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 internal environment continues to be bright providing residents with both pleasant private and communal space. Residents spoken with continue to be positive about staff and the care they receive. Visitors also spoke positively about the care that their relatives receive. The midday meal was observed and it appeared appetising and nutritious, residents spoken with said they enjoyed the meals and had plenty to eat. Staff continue to be able to access a variety of training and clear records are maintained. Regal Care is a responsible provider and will respond to concerns promptly when made aware and provide clear information to the Commission regarding action to be taken following any complaints raised.

What has improved since the last inspection?

The concerns raised regarding medication practice have been resolved and staff now follow the home`s policy and procedure in administering medication to residents in the home. Arrangements have been made for residents who have religious beliefs to attend a service. The quantity of food has also increased at meal times ensuring residents have enough to eat. Residents and visitor were aware of how to make a complaint and information was displayed around the building informing people how to do this.

What the care home could do better:

Communal areas, such as the corridor and stairs were dirty. The Registered Person must ensure that residents` have a clean environment to live in. The Registered Person must ensure that the new manager applies to be registered as `fit person` to manage a care home as soon as possible, thereby ensuring the home is run with in the best interests of the residents. The Registered Person must ensure that care plans are reviewed regularly and where residents needs have changed significantly from admission that re assessments take place to ensure that residents receive appropriate care to meet their needs. Where residents leave the home to visit family or friends arrangements must be made to ensure that their medication is administered appropriately. Residents spoken with said that they did not do very much during the day. The Registered Person must ensure that appropriate activities are arranged to meet the needs of all residents. Residents are not always aware that they can access their care plans and the Registered Person must ensure that residents have regular access to their plans. A requirement was made at the last inspection regarding risk assessing residents for keys to their bedrooms, this has not been completed yet and the Registered Person must ensure that those residents who wish to have a key and are able to use it safely have access to one and that this is recorded in their care plan. The security of the building must be reassessed to ensure it meets all residents` needs. Quality assurance questionnaires and monitoring could be used more effectively in the home showing how the home is run in the best interest of the residents.

CARE HOMES FOR OLDER PEOPLE Hawthorn Lodge Care Home Beckhampton Road Bestwood Park Nottingham NG5 5LF Lead Inspector Susan Lewis Unannounced Inspection 27th April 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.V289993.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.V289993.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 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.V289993.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 26th January 2006 Date of last inspection Brief Description of the Service: The home fees are £350-360. 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 lounge areas. 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 has seen all the communal areas redecorated, along with the residents bedrooms. This work started on 9th May 2005, the communal areas have now been refurbished and many of the bedrooms have also been completed. Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 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 service users and their views of the service provided. The primary method of Inspection used was ‘case tracking’ which involves selecting clients and tracking the care they received through looking at their records, talking with them where possible, and looking at their accommodation. The inspection was unannounced and took place over 8 hours one Thursday in April 2006, and was conducted by one inspector as part of the annual inspection process. A tour of the building took place and a selection of residents’ bedrooms was inspected. Residents’ and staff records were inspected and six residents and a selection of staff on duty were spoken with. What the service does well: What has improved since the last inspection? The concerns raised regarding medication practice have been resolved and staff now follow the home’s policy and procedure in administering medication to residents in the home. Arrangements have been made for residents who have religious beliefs to attend a service. The quantity of food has also increased at meal times ensuring residents have enough to eat. Residents and visitor were aware of how to make a complaint and information was displayed around the building informing people how to do this. Hawthorn Lodge Care Home DS0000061999.V289993.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.V289993.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.V289993.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): 2, 3 and 6 The quality in this outcome area is good. No one moves into the home without having their needs assessed and assured that they will be met EVIDENCE: Intermediate Care is not provided in this service. Each resident has a contract that details the terms and conditions of the service. Four residents were case tracked and all had full assessments of need that covered all aspects of the activities of daily living. Care plans are produced from this information. The home is now registered to admit residents with dementia. On the day of the inspection it was evident that a resident with dementia was not having their needs fully met. It was also evident from information seen that this was being taken up by the registered person as well as the manager and strategies were being looked at to how the home could meet the needs of the individual or where it was no longer possible to liaise with social services to look at appropriate alternatives. Hawthorn Lodge Care Home DS0000061999.V289993.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 The quality in this outcome area is poor. Not all residents’ health, personal and social care needs are set out in an individual plan and their health care needs are not always met. Residents are treated with respect. EVIDENCE: Individual resident’s care plans are in place, these provide bullet point information on how to meet residents assessed needs. Some care plans had temporary plans and it was not clear whether these were current or needed removing. It is unclear if residents or their relatives are included in the care planning process and one plan inspected had not been reviewed for some time. Residents spoken with said that they knew that they had care plans but were not sure if they had been involved in reviewing them. Relatives spoken with said that they were not involved in reviewing care plans. Some plans contained disclaimers signed by relatives or residents saying they did not wish to be involved in care plan reviews. It is recommended that these be regularly reviewed to ensure that this view remains current. Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 Page 10 One plan inspected indicated that the resident was being able to leave the home unescorted, however there was no linked care plan as to how this was to be managed, what actions staff should take if the resident left and did not return. Where residents are able to leave the home unaccompanied care plans should detail what procedure needs to be followed to ensure residents safety. Health care is monitored with records of General Practitioner and District Nurse visits being recorded in files, weight monitoring was recorded in a separate file, showing weight gain and in some cases weight loss. Staff spoken with had raised concern that residents were losing weight due to poor nutrition. No evidence of significant weight loss was found in any residents whose charts were viewed. Further information regarding nutrition is assessed in standard 15. From reading diary notes it was not always clear where concerns were noted by staff regarding tissue viability what follow up if any was made. The Registered Person must ensure that where concerns are noted that appropriate action is taken to maintain residents health. Again reading a residents care plan it stated that the person needed checking ‘hourly’, however on reading the diary notes the resident was actually being checked two hourly. The Registered Person must ensure that staff follow the care plan or if it is no longer relevant review and amend the plan to ensure that the person’s care needs are met at all times. A requirement was set at the last inspection regarding the medication process. Staff had been observed distributing tablets on a teaspoon and walking across the room creating the possibility that they may drop the medication. This practice was not observed during this inspection, residents spoken with said that medication was brought to them in a pot and not a spoon; therefore this requirement is considered met. Residents spoken with said that staff stood with them whilst they took their medication. Most medication records were in order, both temperature of the medication room and the fridge were monitored and recorded. Controlled medication was stored correctly and records were accurate. It was evident form reading the Medication Administration sheet that one resident had not had the sheet signed on a few occasions, following further discussion the manager explained that this was due to the fact the resident in question had gone out with a relative. The Registered Person must ensure that where residents leave the building for any reason a procedure is followed to ensure that residents’ medication is administered appropriately. Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 Page 11 Residents spoken with said that staff treated them with respect and they were able to have regular baths or showers, staff understood how to maintain residents privacy and dignity when providing personal care and residents were seen being encouraged to change their clothes if drinks or food had been split down them. All residents spoken with said that staff were kind and helpful. One resident said ‘I don’t think I could find a better place’. Another resident said that ‘staff always tell me ahead when I am having a bath so I can prepare myself and always treat me with respect’. Staff were observed throughout the day assisting residents and all staff including kitchen assistants, cleaners as well as carers were seen interacting positively with residents, where residents sat alone staff regularly spoke to them as they went past, showing care and attention. Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 The quality in this outcome area is poor. Residents do not always find the lifestyle in the home matches their expectations; residents are helped to exercise choice over their lives but are not always provided with information they need or have a right to. Residents are offered a balanced diet in line with their dietary requirements and plans of care. EVIDENCE: Although there was a list of activities available in the dining area, many residents were not aware of what activities took place. A requirement was made at the last inspection regarding enabling residents to access religious services. Residents spoken with said that they thought someone came in from a local church. The manager confirmed that someone comes in from a local Church of England church as well as a Catholic church. This requirement is now met, however it is recommended that residents be reminded that this activity takes place. Staff were observed sat with residents although some residents spoken with when asked ‘How do you spend you day?’ Replied ‘Not much, we’re sort of left to our self.’ Another resident said that ‘I spend the day as I want, I read or do Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 Page 13 my puzzle books.’ The new manager confirmed that residents meetings are continuing, minutes were not evidenced at this inspection. Residents interests are recorded on care plans, it was not always evident that where residents had dementia what particular consideration was being made for them to be able to participate in activities. The Registered Person must ensure that residents with dementia are provided with suitable leisure activities to meet their needs. Where residents are involved in activities it was not consistently recorded by staff. Residents spoken with all said that they could receive visitors in private and they could use either their bedroom or a quite room upstairs. Visitors spoken with said they were made to feel welcome, however one relative said ‘I have visited before and not been able to find my mother, and wandered around for ages without anyone checking what I was doing’. The Registered Person must ensure that staff are reminded of the need to ensure visitors are made to feel welcome and to check visitors know where to find their relatives. All residents spoken with said that they had been able to bring personal possessions into the home and bedrooms viewed showed that they were personalised. Personal choice is offered throughout the home, and residents spoken with said that they could get up and go to bed when they wanted to. Residents spoken with still were unsure about their right to access their personal records in accordance with The Data Protection Act 1998. The Registered Person must ensure that residents are regularly reminded of this right. The menu system offers a well-balanced diet, and is provided to residents at a time to suit them. All residents spoken with said that they enjoyed the meals and that they thought the quality had improved with the arrival of the new cook. Some staff expressed concern that the cook concentrated on providing healthy food rather than what residents wanted and as such lost weight. This was detailed in standard 8 and no evidence was found to substantiate that residents were loosing weight. The mealtime was observed and residents were seen to eat the meal provided and those spoken with said that they enjoyed it. A requirement was made at the last inspection to ensure that sufficient food was available at all mealtimes. Residents spoken with said that they had enough to eat. Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 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 inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 The quality in this outcome area is good. Residents and their relatives are confident that their complaints will be listened to, taken seriously and acted upon. Management take action necessary to protect residents from abuse. EVIDENCE: A requirement was made at the last inspection to ensure that visitors and residents knew how to make a complaint as no evidence of a copy of the complaints procedure was seen around the building. Notices were seen and this requirement is now met. Residents spoken with said that they knew who to complain to if they felt unhappy with anything and visitors spoken with said that they felt able to raise issues of concern with the manager and felt it would be listened to and dealt with. A relative was spoken with who raised concerns regarding her relatives care. This was passed to the manager to look further into and provide an outcome to the relative. Residents spoken with said that they felt safe and that staff treated them kindly and did not shout at them. Staff spoken with said that they received Adult Abuse Awareness Training and were aware of what to do if they witnessed a member of staff treat a resident badly. Evidence was seen that management of the home have dealt with allegations of abuse appropriately and followed Nottingham City Council Protecting Vulnerable Adults procedures. Residents’ finances are dealt with in a secure manner protecting them from financial abuse. Hawthorn Lodge Care Home DS0000061999.V289993.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, 24 and 26 The quality in this outcome area is adequate. Residents live in well-maintained internal environment. The home is clean and hygienic. EVIDENCE: The layout is suitable for its stated purpose. It is accessible, safe and internally well maintained. The programme of refurbishment is near completion and communal rooms are looking significantly brighter and more pleasant for residents to live in. However it was observed in some communal areas (the corridors and stairs) that they were dirty and needed cleaning. The grounds are not well maintained and do not provide residents with an attractive area to enable residents to access sunlight. Although not a requirement at the last inspection it has been a requirement in the past and the Registered Person must ensure that the grounds continue to be maintained regularly to ensure residents have a pleasant safe garden to access. A requirement was set at the last inspection to ensure that all residents have a key to their bedroom unless a risk assessment suggests otherwise. Evidence Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 Page 16 was not seen that this has been met. The Registered Person must ensure that this is carried out promptly. It was observed in a number of residents’ bedrooms that the bed linen was worn and threadbare. The Registered Person must ensure that residents have suitable bed linen in the absence of their own. The Registered Person must ensure that this is carried out to ensure that residents privacy and dignity. The home was clean and residents spoken with confirmed that their bedrooms were clean and that their clothes were washed and came back. The laundry is on the first floor and situated away from the lounge and dining areas so soiled articles are not carried through areas where food is stored, prepared, cooked or eaten. Hawthorn Lodge Care Home DS0000061999.V289993.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 The quality in this outcome area is poor. Residents’ needs are mostly met by the numbers and skill mix. Residents are not always protected by the home’s recruitment policies and procedures. Staff receive training to enable them to do their job. EVIDENCE: The review officer from Nottingham City Council has been carrying out a review of quality of care within the home and raised concerns both with the acting manager and the inspector regarding apparent low staffing. Staffing figures were looked at and appeared to meet the needs of the residents at the time. Residents spoken with said that staff were always busy but would be there to help them when they needed. One resident said that she had pulled her bell and it had taken 45 minutes for someone to come. However this was not the experience of all residents spoken with. It is however recommended that the Registered Person look at the staffing in relationship to the service user who regularly absconds. Evidence was seen that staff receive regular access to a variety of training courses including induction training and NVQ training. Staff files inspected showed that recruitment is not always carried out to the homes policies and procedures as not all files had copies of up to date Criminal Records Bureau in evidence. All files had two references collected to ensure residents safety. The Registered Person must ensure that appropriate checks are made to ensure the safety of residents. Hawthorn Lodge Care Home DS0000061999.V289993.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): 31, 33, 35 and 38 The quality in this outcome area is adequate. The home is run in the best interests of the residents and their financial interests are protected. The health, safety and welfare of residents are mostly promoted. EVIDENCE: There is currently a new manager in post and has yet to registered as ‘fit person’ with the Commission. The new manager has a positive approach to learning and the needs of the residents at the home as well as ensuring staff are supported in their role. Staff spoken with said that they found the manager supportive. Regal Care has a quality audit system and copies of questionnaires are routinely sent to the Commission. It would be advantageous for questionnaire results to be made public in the Statement of Purpose and Service User Guide or brochure of the home. Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 Page 19 Suitable financial arrangements are in place to ensure that written records are kept of all transactions made by residents. Residents spoken with said ‘When I need money for my hair I ask the staff and I can have it without any problems.’ Or ‘My relative deals with that side of things’. There was evidence on some care plans that inventories had been made of some residents’ possessions on entering the home. It is recommended that this is carried out for all residents. Internally the home is maintained to a high standard. Evidence was seen regarding the recording of issues pertaining to Health and Safety in the home and all appropriate information is recorded in diary notes and care plans. However in discussion with one relative it was raised that their relative had fallen but it had not been recorded nor had they been told. In discussion with home staff it was clear that although the home’s policy is to contact relatives at the earliest convenient time this had not been followed. The Registered Person must ensure that procedures are followed regarding accidents involving residents and that all appropriate documentation is filled out and where the incident affects a residents the Commission must be informed. The Registered Person must also risk assess the security of the building in light of the resident who absconds. Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 X X X X 1 X 3 STAFFING Standard No Score 27 3 28 3 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 2 Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 Page 21 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 OP7 Regulation 15(1)(2) Requirement The Registered Person shall unless it is impracticable to carry out such consultation, after consultation with the resident, or a representative of his, prepare a written plan (the service users plan) as to how the resident’s needs in respect of his health and welfare are to be met. The registered person shall make the resident’s plan available to the resident keep the resident’s plan under review. The Registered Person shall ensure that the assessment of the service users needs is kept under review; and revised at any time when it is necessary to do so having regard to any change of circumstances. Where the resident’s needs have changed a reassessment must take place. The Registered Person shall ensure that the care home is conducted so as to promote and make proper provision for the health and welfare of service users. Where diary notes identify residents have possible skin problems these must be followed up with the GP and appropriate treatment given. DS0000061999.V289993.R01.S.doc Timescale for action 01/08/06 2 OP7 14(2) 01/07/06 3 OP8 13(1) 01/07/06 Hawthorn Lodge Care Home Version 5.1 Page 22 4 OP9 13(1) 5 OP12 16(2) 6 7 OP14 OP19 15(2) 23(2) 8 OP24 12(4) The Registered Person shall make arrangements for resident’s safe administration of medication. Where residents leave the building to visit relatives or other such activity arrangements must be made for them to be able to receive their medication. The Registered Person shall consult residents about their social interests, and make arrangements to enable them to engage in local, social and community activities and to visit, or maintain contact or communicate with, their families and friends, consult residents about the programme of activities arranged by or on behalf of the care home, and provide facilities for recreation including, having regard to the needs of residents, activities in relation to recreation, fitness and training. Activities must be arranged for residents with dementia. The Registered Person shall make the residents plan available to the resident. The Registered Person must ensure that the external grounds are suitable for, and safe for use by, residents are provided and appropriately maintained. 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. (Outstanding requirement 26/01/06) 01/07/06 01/08/06 01/08/06 01/07/06 01/08/06 Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 Page 23 9 OP29 19(1) Schedule 2 10 OP38 13(4) 11 OP38 37 The registered person shall not employ a person to work at the care home unless the person is fit to work at the care home and suitable police checks have been obtained. The Registered Person shall ensure that all parts of the home to which residents have access are so far as reasonably practicable free from hazards to their safety any activities in which residents participate are so far as reasonably practicable free from avoidable risks and unnecessary risks to the health or safety of service users are identified and so far as possible eliminated. The security of the building must be reassessed in light of the resident who absconds. The registered person shall give notice to the Commission without delay information regarding all significant events, which adversely affect residents. 01/06/06 01/06/06 01/06/06 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 OP7 Good Practice Recommendations Where residents/relatives have signed a disclaimer saying they do not wish to be involved in reviews these should be reviewed to ensure they remain relevant to residents/relatives wishes. Staffing levels should be reviewed in light of the resident who absconds 2 OP27 Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 Page 24 3 OP33 It would be advantageous for questionnaire results to be made public in the Statement of Purpose and Service User Guide or brochure of the home. Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 Page 25 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. Extracts may not be used or reproduced without the express permission of CSCI Hawthorn Lodge Care Home DS0000061999.V289993.R01.S.doc Version 5.1 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. 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