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 made no statutory requirements on the home as a result of this inspection
and there were no outstanding actions from the previous inspection report.
CARE HOMES FOR OLDER PEOPLE
Hawthorn Lodge Nursing Home 2 Canberra Grove Hartburn Stockton-on-Tees TS18 5EL Lead Inspector
Julia Connor Unannounced 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 Nursing Home DS0000000172.V266253.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 Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Hawthorn Lodge Nursing Home Address 2 Canberra Grove Hartburn Stockton-on-Tees TS18 5EL 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) 01642 570100 Mr M Ramdhan Mrs K Ramdhan Ms Jacqueline Jane Pallister Care Home 30 Category(ies) of Old age, not falling within any other category registration, with number (30), Physical disability over 65 years of age (0) of places Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. To allow the admission of up to 5 service users Physical Disability 55 years . Total occupancy of the care home not to exceed maximum number of 30. To admit one named service user who is below the age category that the home is registered for. 22nd August 2005 Date of last inspection Brief Description of the Service: Hawthorn Lodge is a care home providing both nursing and personal care for older people. It is a converted Victorian building with an extension. The 26 single bedrooms are a minimum of 10 sq.m. The 2 double bedrooms are a minimum of 16 sq.m. There are 3 lounges and a large dining room. There is a passenger lift giving access to both floors. The home is opposite a parade of local shops. There is a small car park at the back of the home. Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection commenced at 10.00 a.m. and concluded at 1.20 p.m. Five Residents’, one visitor and two members of staff were spoken to during the inspection. Three comment cards from family members/friends were returned. What the service does well: What has improved since the last inspection? What they could do better:
The Manager must establish a formal contract with the company that removes the medication belonging to the Residents’ that receive nursing care. Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 6 The Manager must ensure there is a photograph of the member of staff in their personnel file. The Manager should ensure that 50 of the care staff have their NVQ Level 2 in care. The Manager should ensure the home is kept in a good state of repair for example the corridor carpet next to the dining room requires a deep clean; the flooring in bathroom two requires a deep clean and the damaged tiles should be replaced. The flooring in bathroom one requires a deep clean or replacing. 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 Nursing Home DS0000000172.V266253.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 Nursing Home DS0000000172.V266253.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): EVIDENCE: Standards 1 - 5 were not assessed on this occasion. applicable. Standard 6 is not Hawthorn Lodge Nursing Home DS0000000172.V266253.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): 9 Medication is dispensed appropriately and Residents’ are protected by the home’s policies and procedures for dealing with medication. EVIDENCE: There is a policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. No Resident currently self medicates. The Manager should establish a formal contract with the company that removes the medication belonging to the Residents’ that receive nursing care. Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 10 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 and 14 Activities take place within the home. Residents’ are encouraged to make choices in their every day lives and maintain contact with family and friends. EVIDENCE: Residents’ who spoke to the Inspector stated that ‘there were things to do’ but it was up to them whether they participated or not. One Resident stated that she like to read, watch TV or chat with the other Residents’. On the day of the inspection there were Residents’ watching TV and reading books or magazines. Two Residents were sat in the entrance, as they liked to ‘watch the comings and goings of visitors’. The Residents’ who spoke to the Inspector stated that there were encouraged to make their own decisions regarding their every day lives. They stated that although the staff encouraged them to do as much for themselves as possible, they were there should help be needed. The Residents’ who spoke to the Inspector stated that they maintained contact with their family and friends. There were visitors’ in the home at the time of the inspection. One Resident was going out with her daughter for a few hours. Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 11 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 Residents’ are confidant that their complaints would be listened to seriously and action taken. EVIDENCE: There is a complaints policy and procedure in place, which outlines the stages the complainant should take to make a formal or informal complaint. The Residents’ who spoke to the Inspector stated that they would speak to the Manager if they had any complaints or concerns and were confident that she would take the appropriate action. Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 12 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 and 26 Residents’ live in a predominantly well-maintained environment that is clean and hygienic. EVIDENCE: On the day of the inspection the handyman was observed to be decorating a bedroom. The corridor carpet next to the dining room requires a deep clean. The flooring in bathroom two requires a deep clean and the damaged tiles should be replaced. The flooring in bathroom one requires a deep clean or depending on the outcome replacing. On the day of the inspection the home was clean, pleasant and odour free. Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 13 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 and 29 Resident’s needs are met by the number of staff on duty. Staff are being trained to NVQ level 2 which should ensure that they can meet the Residents needs. The staff personnel files do not contain the required information. EVIDENCE: An audit of the duty rota was carried out. There is one trained nurse and four care assistants on the morning shift, one trained nurse and three care assistants on the afternoon/evening shift and one trained nurse and two care assistants on the night shift. There are twenty care assistants working at the home; seven staff currently have their NVQ Level 2 or 3. A further four members of staff are doing their NVQ training. Four personnel files were audited; none contained a photograph of the member of staff as stipulated in Schedule 2 of the Care Homes Regulations 2001. Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 14 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): 33 There is a quality assurance and quality monitoring system in place. EVIDENCE: Regulation 26 reports are sent to the Commission for Social Care Inspection every month, which covers areas such as cleanliness and decor; questionnaires are sent to Residents’ and their family members’ for their opinion of the service provided. The 2005 quality assurance report is currently being written. Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 15 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 2 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 2 29 2 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 3 X X X X X Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 16 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 Requirement Timescale for action 31/03/06 2 OP29 19 The Registered Person must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the care home. The Registered Person must not 31/03/06 employ a person to work in the care home unless s/he has obtained the information stipulated in Schedule 2 of the Care Home Regulations 2001, e.g. a recent photograph of the member of staff. 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 OP19 Good Practice Recommendations The Manager should ensure that the following areas receive attention: • The corridor carpet next to the dining room requires a deep clean.
DS0000000172.V266253.R01.S.doc Version 5.1 Page 17 Hawthorn Lodge Nursing Home 2. OP28 The flooring in bathroom two requires a deep clean and the damaged tiles should be replaced. • The flooring in bathroom one requires a deep clean or depending on the outcome replacing. The Registered Manager should ensure that 50 of the care staff have an NVQ Level 2 in care. • Hawthorn Lodge Nursing Home DS0000000172.V266253.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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