Inspection on 12/06/06 for Hawthorne Lodge

This inspection was carried out on 12th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hawthorne Lodge 08/06/10

Hawthorne Lodge 10/05/10

Hawthorne Lodge 17/02/10

Hawthorne Lodge 06/01/10

Hawthorne Lodge 30/11/09

Hawthorne Lodge 06/11/09

Hawthorne Lodge 06/10/09

Hawthorne Lodge 19/08/09

Hawthorne Lodge 07/04/08

Hawthorne Lodge 11/05/07

Hawthorne Lodge 23/01/06

Hawthorne Lodge 22/09/05

Hawthorne Lodge 30/03/05

Hawthorne Lodge 05/08/04

Hawthorne Lodge 23/03/04

Similar services:

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

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

CARE HOMES FOR OLDER PEOPLE Hawthorne Lodge 164/166 Hawthorne Road Bootle Liverpool Merseyside L20 3AR Lead Inspector Mrs Claire Lee Unannounced Inspection 9:45 12th June 2006 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 Hawthorne Lodge DS0000005377.V291695.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. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hawthorne Lodge Address 164/166 Hawthorne Road Bootle Liverpool Merseyside L20 3AR 0151 933 3323 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) Stirrupview Limited Property & Estates Mrs Lea Jones Care Home 25 Category(ies) of Old age, not falling within any other category registration, with number (25) of places Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 25 OP Date of last inspection 23rd January 2006 Brief Description of the Service: Hawthorne Lodge is registered to provide accommodation and personal care without nursing for twenty five older people. The home is a mock Tudor style building located on the corner of two busy streets in Bootle. Due to its location there is good access to public transport, and many local facilities are a short journey away. The shared areas include two lounges, a dining room and walled back garden. Bedrooms are either single or double rooms, screens are provided in double rooms for privacy. The home has a passenger lift and chair lifts access rooms that have a number of stairs to them. The home has a small grassed area with patio furniture to the rear and there is also car parking space. A keypad fitted to the front door and other doors are alarmed so that staff are aware of and can offer assistance to any resident who wishes to go out. The home provides twenty-four hour personal care to residents; meals and laundry costs are included in the basic fee. The fee rate is currently £355.00 a week. The home will arrange for newspapers, hairdressers, private chiropodists and dry cleaning and these costs are met by the resident. In the past there have been a number of thefts from the home and subsequently following police involvement the home has CCTV cameras which view the laundry room, office, store room and corridors only. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days, approximately eleven hours. It was an unannounced inspection (site visit) and was carried out as part of the regulatory requirement for care homes to be inspected. A partial tour of the home was conducted and care records and other home records were viewed. Discussion took place with the principal carer, the owner and manager, three care staff, the cook, handyman and seven residents individually. Group discussion also took place with the residents available during the visit. Fourteen residents were accommodated at this time. During the inspection three residents were case tracked (their care files were examined and their views of the home were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. Discussion also took place with two relatives. All the key standards were inspected and also previous requirements and recommendations from the last inspection on 23rd January 2006 discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents and relatives prior to the inspection. Comments included in the report are taken from the survey forms and also during the site visit. What the service does well: The home provides good information regarding the service and this assists residents when deciding to take up residency. A resident said he was made welcome by staff when he arrived. The home carries out a care needs assessment before offering a place to new residents. The assessment details past and current health care needs and the information is then used to form the basis for the plan of care. Residents are also provided with a contract stating terms and conditions of residency. Residents and relatives spoken with were pleased with the standard of care and staff were described as “Good”, “Caring”, and “Helpful”. Residents interviewed stated that they could choose what time to get up in the morning or retire at night and that the staff respect their wishes with regard to personal care. The home offer access to external health professionals and the District Nurse Service provides clinical support when required. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 6 Staff are offered a training programme, which includes courses in safe working practices and also adult protection. 70 staff have a national vocational qualification (NVQ) in care. The home has policies and procedures to protect the welfare of the residents and staff. Residents and relatives confirmed they can speak with the manager and staff at any time and that they are provided with survey forms which enable them to give their views of the home. What has improved since the last inspection? What they could do better: Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 7 Residents have an individual plan of care however the home must ensure residents are fully involved with the care plan process and the care reviews. The home has a duty of care to ensure a resident has been risk assessed as being able to administer his or her own medication safely. An activities programme must be implemented to enable residents to continue with their preferred social interests. Residents should be approached to enable them to voice their opinions as to the programme of events to be arranged. With regards to the general cleanliness of the building a number of bedrooms required cleaning and lounge carpets were soiled. This must be addressed to improve the overall standard of hygiene. There was no domesic cover on the first day of the inspection however this was provided on the second day. An infection control procedure has been implemented following the last inspection however this document could not be located and it was agreed to forward a copy to the Commission. The exterior paintwork requires attention however the owner, Mr Hornby, confirmed that this work would be undertaken later this year. Staff receive training in safe working practices and manual handling is to be arranged for staff members who did not attend the training in January 2006. Maintenance contracts for services to the home were available however the contract for the bath hoist, chair hoists and manual handling hoist could not be located. These are to be forwarded to the Commission. 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. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 3 (Standard 6 - Intermediate care is not provided ) The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are provided with comprehensive information to enable them to decide whether to take up residency at the home. Pre admission assessments help ensure that the home can meet the needs of the residents and residents are provided with a contract stating terms and conditions of residency. EVIDENCE: Residents and/or their relatives are given copy of the home’s Statement of Purpose and Service User Guide. This information can be found in residents’ rooms. They are also given a welcome pack and it was agreed to forward a copy of this booklet to the Commission. A resident interviewed stated that their family had come to look round the home and that they had been given sufficient information regarding the service. A staff member confirmed that prospective residents are welcome to look round at any time. Residents are provided with a contract stating terms and conditions of residency. Fee details were included and clearly laid out. This means that residents have the information they need about the service they will receive Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 10 and how much it will cost them. Three contracts seen had been signed by the resident and manager, they were however not dated. Many of the residents have lived at the home for many years and as part of the case tracking process an assessment was viewed or a resident who has recently been admitted. The assessment recorded previous medical history, preferred interests and also details of personal care and support needed. There was little detail recorded regarding social care and family background, which would be beneficial when setting up the plan of care. A resident said, “The staff made me very welcome when I arrived at the home and are giving me the care I need”. Copies of assessments from social workers are kept on file and these identify the type of care and support the resident requires. Intermediate care is not provided at Hawthorne Lodge. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 11 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 good. This judgement has been made using available evidence, including a visit to this service. Residents have a plan of care however they need to be more involved with the care plan process to ensure they are kept fully advised of their care provision. Residents who wish to self administer their medications are not risk assessed to ensure they are able to undertake this practice safely. Residents are treated with respect and dignity. EVIDENCE: Three resident care files were seen as part of the case tracking process. The care files were organised and the information easy to read. A resident stated that they were unaware of the their plan of care and several residents interviewed were unsure of the care plan process and reviews of care documentation that are undertaken by the staff. One file contained a review with a family member however this is little evidence of residents’ involvement in developing their plan of care. The plan of care contains basic information and includes a risk assessment for mobility and personal safety. A general risk assessment is in place regarding personal care with details of hearing, sight and diet. Residents are weighed to monitor any weight loss or increase. A personal profile is completed by the residents regarding their lifestyle and Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 12 interests prior to entering the home. Access is available to health care services and all visits are recorded either in the care file or a separate sheet in the daily record log. The daily record sheet evidenced the most recent visits. This included hospital and chiropody appointment. A resident said, “I can see my GP whenever I want.” There are no residents receiving care from the District Nurse Service at the time of the inspection. A chiropodist visits the home every three months. Completed comment cards refer to residents receiving the medical support and care they need. A resident said, “The care is fine in the home”. The home should complete a risk assessment for residents who smoke and consider the provision of a fire blanket for residents who smoke in their bedroom. Smoking is currently permitted in one bedroom on the ground floor and also in the dining room. The home should look to monitor smoking in the dining room especially around meal times, as this may affect residents who do not wish to eat in this environment. Medicines given out had been signed for on the medicine sheets seen. It was noted that several residents had refused a number of medicines during this month and the home should contact the GP to ensure he/she is aware of their refusal. The quantities of medicines received in the building had been entered on the medicine sheets. Residents can self administer their medication and a resident had competed a consent form for this practice. This should contain details of the medicines to be self administered and updated periodically. The home has a duty of care to ensure a resident has been risk assessed as being able to administer their own medications safely and that this does not pose a risk to other residents in the building. This practice must be carefully monitored when a resident is not taking medications at the prescribed time. This was evidenced during the inspection. With regards to the medicine Temazepam (night sedation) it is good practice to have two members of staff sign the medicine sheet or a separate record book following its administration. Medicines are administered from blister packs and are given out by staff who received medicine awareness training in 2003. Staff were observed assisting residents with various aspects of their personal care and this was carried out in an unhurried manner. Residents confirmed that they have help with bathing either in the morning or afternoon. A resident said, “Staff are always polite and help me”. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 13 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 adequate. This judgement has been made using available evidence, including a visit to this service. Residents are able to choose how they spend their day however the home offers no activity programme to encourage residents to continue with their preferred social interests. Residents are offered well balanced meals at regular intervals. EVIDENCE: The home does not offer any structured activity programme. Several residents confirmed that they want activities to be organised as, “There is not a lot to do during the day”. Throughout the morning of this visit residents were occupying themselves by reading or watching TV. The home used to offer a social programme however there is nothing in place at present. Completed comment cards refer to activities not being organised and staff interviewed commented that social interests would improve the residents’ stay at the home. The manager must devise and implement an activities programme and residents should be approached to enable them to forward their ideas. The home offers holy communion therefore residents can continue to practice their faith. Social arrangements for a resident were discussed with regard to the home arranging visits to local clubs and community based centres. The residents are able to view television in their own rooms or in the two lounges and dining room. The lounges are smoke free. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 14 Visitors are welcome at any time and a number were seen meeting with residents in their own room or the dining room. A relative said, “We come in each day and can spend as long as we want”. Residents spoken with said they have the choice to remain in the privacy of their own room or use the lounge areas and dining room to mix with others. The manager confirmed that an advocate would be approached on behalf of the resident at the appropriate time. Details of this service are incorporated in the welcome pack. The menu is based over four weeks and residents interviewed were pleased with the choice of food. The main mean is served at lunchtime and a ‘lighter’ meal at teatime. There was no menu on display in the dining room and this should be made available to the residents to ensure they are aware of the choice at each mealtime. The kitchen has been decorated and the home are meeting the requirements from the most recent environmental health visit. A new floor is also being laid as the existing one has water damage; the manager confirmed that this is on order. Fridge, freezer and hot food temperatures are recorded daily and records seen were current. The cook has a certificate in basic food hygiene. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 15 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 an 18 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents and relatives have confidence that their concerns will be dealt with. Abuse policies and procedures are in place to protect the residents. EVIDENCE: The home has a complaint procedure and since the last inspection a copy of this has been provided to all the residents and/or their relative. A care file evidenced that a resident had signed to say they had received this information. Several staff members interviewed discussed the line of action that should be taken if a resident wished to make a complaint however were unsure where the complaint procedure is kept. They should be aware of its location, as they may need to refer to the procedure. The home’s complaint log was seen and this evidenced investigations undertaken by the manager. A relative said he would always speak up if he was unhappy about anything and “Staff put things right straight away”. The training record viewed showed that abuse training has been provided to staff to ensure they are aware and understand the adult protection procedures. Staff have access to an abuse policy and the home has a copy of Sefton’s local procedure. The home’s recruitment procedure ensures staff have obtained the necessary police check to enable then to work in the home. Residents monies are recorded, receipts and signatures obtained and balances are regular updated. Three financial records viewed evidenced that personal allowances are distributed monthly and signed on receipt by the resident. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 16 Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 17 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, 25 and 26 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home does not contribute to the quality of life for the residents, as certain areas of the home were not clean and maintained to a good standard. EVIDENCE: The home has an ongoing programme of maintenance and a handyman completes every day jobs. The home has as passenger lift to all floors and two chair lifts to rooms, which can only be accessed by a small number of stairs. The home has a hipbath (a bath designed to assist resident who are less independent) and three other bathrooms. One has a bath hoist. The bathrooms have been decorated but are stark in appearance and would benefit from being made more personal with pictures or stencils. New toilets have also been fitted and these have raised toilet seats and handrails to assist the residents. A ground floor toilet door situated by the laundry room is in need of repair as the woodwork is broken. Seven bedrooms have recently been decorated and bedrooms viewed were adequately furnished and had personal items and electrical equipment belonging to each resident. The home has five double Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 18 bedrooms. A resident said, “I like my room and it is comfortable”. A number of bedrooms viewed were in need of cleaning and bedroom carpets were in need or vacuuming. The carpet in Room 21 was rucked posing a trip hazard to the resident. The home has a dining room and a lounge on the ground floor and another lounge situated on the first floor. The carpets in both lounges are badly soiled and in need of urgent cleaning or they must be replaced if the stains cannot be removed. The lounges have armchairs and sofas. As previously stated smoking is currently permitted in the dining room. This means that residents do not always have a comfortable environment in which to enjoy their food. Hot water temperatures to the baths and sinks are recorded to ensure it is delivered to a safe temperature to the residents. Emergency lighting is provided throughout the building and subject to an annual safety checks. Monthly in house checks of the emergency lighting were undertaken up until 2004. These should be undertaken monthly and further advice can be sought from the fire safety department regarding the frequency of these checks. The home has a manual handling hoist to assist residents if their mobility is restricted. The laundry room is situated on the ground floor and care staff undertake laundry duties each day. The home has gloves and aprons for staff use however gloves could not be located on the first day of the inspection. A supply was seen the next day. Laundry items were also found on the floor and this was corrected when pointed out to a staff member. At the last inspection the home was asked to provide an infection control procedure. The manager stated that this has been obtained however it was not available at this time. A copy of the document is to be forwarded to the Commission. Staff have attended infection control training in March 2006. Residents interviewed stated that the laundry service was efficient. There is a small garden to the rear of the building accessed via the dining room. The garden is not landscaped but has patio furniture. The exterior of the home requires painting and the owner confirmed that this is planned for this year. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 19 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 good. This judgement has been made using available evidence, including a visit to this service. Sufficient numbers of trained staff are on duty to care for the residents. Residents are protected by the homes recruitment processes, which include appropriate checks for all staff. EVIDENCE: During the morning of the inspection a principal carer was on duty with two care staff, a cook and handyman. Three care staff including a principal of care were on duty in the afternoon. The home employs two domestics; however there was no domestic cover on the fist day of the inspection and the lack of cleaning compromised the general cleanliness of the building. At night two care staff are employed. The staffing rota was seen for May and the first two weeks of June. This evidenced sufficient numbers of staff to care for the residents. Care staff undertake laundry duties, which they confirmed they were able to complete along side their care work. The home does not use agency staff as permanent staff cover any outstanding shifts. In the manager’s absence, the deputy manager, a principal carer or senior carer is in charge. Staff receive ongoing training in safe working practice areas including manual handling, first aid, food hygiene and infection control. Staff files seen contained a number of certificates for courses attended and the more recent are currently kept in a training file. The home must arrange a date for staff who were unable to attend the more recent manual handling instruction. Medicine awareness training was given in 2003 and it is recommended that further Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 20 training be given and/or the manager complete a competency assessment for those responsible for administering medications. 70 of staff have achieved a care qualification in NVQ. There was evidence of completed staff inductions on file. Staff members are therefore given the right information to be able to do their jobs well. Three staff files seen evidenced that the home’s recruitment procedure is followed. Staff files contained completed job application forms, two references and a criminal record bureau disclosure at enhanced level. Staff are given terms and conditions of employment. Residents interviewed said that staff were “Friendly”, “Helpful”, “Chatty” and “On hand”. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 21 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): 31,33,35,36 and 38 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has a registered manager who is undertaking the necessary management qualifications. The home has a management team to support the manager. Health and Safety policies and procedures in place however a small number were not available to protect the welfare of the residents. EVIDENCE: Mrs Lea Jones, manager, is currently on maternity leave but was present for the second day of the inspection. Mrs Jones is experienced in managing a care home for older people and has almost completed her NVQ Level 4 in Management. The manager is returning to work in July 2006 though remains in contact with the deputy manager and the owner, Mr Hornby. Residents interviewed knew that the manager was on maternity leave and who to approach in her absence. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 22 Mr Hornby’s daughter who assists with resident’s finances undertakes a monthly visit to the home and forwards a report of her findings to the Commission. A copy of the visits was not available and these should be kept at the home for future inspections. Survey forms are sent out to residents and/or their relatives at least twice a year to obtain their views of the home. A completed survey form was seen and parts completed were positive regarding the overall service. The manager stated that residents did not want resident meetings organised and this was confirmed by two residents interviewed who did not felt they would be beneficial. Policies and procedures are reviewed on a regular basis and it is recommended that the manager include the date of review when undertaking this work. If they wish to residents are helped to take responsibility for managing their own money. Three financial records evidenced recent expenditures and staff and resident signature for personal allowances. A financial query raised by a resident was passed to the manager for her attention. The home has a safe to keep valuables and money. Maintenance contracts for the gas, electric, lift, fire prevention equipment and portable appliances were seen. These were in date. It was agreed that a copy of the safety certificate for the manual handling hoist, bath hoist and chair lifts is be forwarded to the Commission as these were not available. The manager stated that these were in date. Fire alarms are tested weekly and fire prevention training is arranged for staff. Fire training should be given at least every six months and further information regarding the frequency of this can be obtained from the fire safety department. Fire drills are conducted for staff and residents. Staff are receiving supervision and staff files record the meetings. Handovers also take place to ensure staff are aware of the residents’ needs. The accident book was seen and recent entries were viewed. This evidenced a record of incidents affecting the residents well being and action taken by staff. Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 23 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 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 X 2 Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15 Requirement The home must ensure residents are consulted with regard to their plan of care and are involved in the review process. The home must compete a risk assessment for residents who wish to self administer their medications. The home must devise and implement an activities programme to suit residents’ needs The home must decorate the exterior of the building The home must clean the carpets identified in the report or replace them if the soiled areas cannot be removed. The rucked carpet in Room 21 must also be re laid. The home must kept all areas of the home clean and forward a copy of the home’s infection control procedure to the Commission. The home must arrange training in manual handling for staff who did not attend in January 2006. The home must forward a copy DS0000005377.V291695.R01.S.doc Timescale for action 12/08/06 1. OP9 13 12/07/06 2. OP12 16 12/07/06 3. 4. OP19 OP19 23 23/16/13 12/07/06 12/07/06 5. OP26 13 12/07/06 6. 7. OP30 OP38 18 13/23 12/08/06 12/07/06 Page 25 Hawthorne Lodge Version 5.1 of the safety certificate for the manual handling hoist, bath hoist and chair lifts to the Commission. 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. 2. 3. 4. Refer to Standard OP1 OP2 OP3 OP8 Good Practice Recommendations The home should forward a copy to the Commission of the welcome pack given to residents when they move to the home. The home should ensure resident contracts are dated when they are signed. The home should record details regarding social care in the assessment. The home should complete a risk assessment for residents who wish to smoke in the building and consider the provision of a fire blanket for residents who smoke in their bedroom. The home should ensure the consent form for residents who wish to self administer their medications includes a list of medicines prescribed. The home should monitor the effects of smoking in the dining room. The home should ensure the menu is made available for residents. The home should ensure staff are aware of where the complaint procedure is kept. The home should undertake in house checks each month of the emergency lighting and contact the fire safety department for further advice if needed. The home should arrange medicine awareness training for staff and/or the manager should complete a competency assessment for those staff responsible for administering medicines. When reviewing policies and procedures the manager should enter a review date. 5. 6. 7. 8. 9. 10. OP9 OP10 OP15 OP16 OP25 OP30 11. OP38 Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Hawthorne Lodge DS0000005377.V291695.R01.S.doc Version 5.1 Page 27 - 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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