Inspection on 07/04/08 for Hawthorne Lodge

This inspection was carried out on 7th April 2008.

CSCI found this care home to be providing an Good service.

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 11/05/07

Hawthorne Lodge 12/06/06

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 Key Unannounced Inspection 7th April 2008 08:45 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.V360548.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 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) Lea@hawthornelodge.co.uk 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.V360548.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 25 OP Date of last inspection 11th May 2007 Brief Description of the Service: Hawthorne Lodge is registered to provide personal care 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 small back garden. Bedrooms are either single or double rooms, screens are provided in double rooms for privacy. The home has a passenger lift and there are chair lifts to access rooms that have a number of stairs to them. 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. Bathrooms have equipment to help residents with bathing arrangements. Residents have the use of a call bell with an alarm facility. CCTV cameras view public areas only. There is car parking space to the side of the premises. From 7th April 2008 the weekly fee rate for accommodation is £374.90p. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 stars. This means the people who use this service experience good quality outcomes. A site visit took place as part of the unannounced inspection. It was conducted over one day for a duration of approximately eight hours. Eighteen residents were accommodated at this time. A partial tour of the premises took place and a number of care, staff and health and safety records were viewed. Discussion took place with six residents, two relatives, three staff and the manager. During the inspection three residents were case tracked (their care files were examined and their views of the service were obtained). This was not carried out to the detriment of other residents who also took part in the inspection. All the key and other standards were inspected during the site visit. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents, relatives and staff prior to the inspection. A number of comments received from surveys and interviews that were conducted are stated in this report. An AQAA (annual quality assurance assessment) was completed by the manager prior to the site visit. The AQAA comprises of two self questionnaires that focus on the outcomes for people. The self assessment provides information as to how the manager and staff are meeting the needs of the current residents and a data set that gives basic facts and figures about the service, including staff numbers and training. Information from the AQAA is included in this report. What the service does well: Residents and relatives reported that they were pleased with the overall service and that they had noted a number of changes in relation to improving the accommodation. A resident said, “I am very happy here and I am sure it will always be that way”. A resident who has not long arrived at the home said he had been made very welcome and that the staff had made sure everything was ready in his room on arrival. There was a relaxed, friendly atmosphere and staff were seen to spend time with residents and relatives chatting to them in the lounge. Visitors were made welcome and offered light refreshments. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 6 A health and social care assessment had been completed by the manager for residents who wished to take up residency. The manager therefore makes sure that the staff only care for those people whose needs they can meet. The residents’ care plans contained a lot of important information about what they needed help with, and how they were to be cared for. The information had been gathered from the initial assessment and by getting to know the resident. The plan of care also identified specialist care according to need with input from outside health professionals. A resident said, “I can see my doctor at time I want.” Residents were complimentary regarding the choice of foods prepared each day and they said that they had plenty to eat. Cooked breakfasts are popular and the meal at lunch time looked appetising. Residents were given a stew and a resident said, “Scouse (stew) is one of my favourites.” The manager is making sure that the staff are properly trained and that they have the knowledge and skills they need to protect and meet the needs of the residents. There was evidence of a good training programme. What has improved since the last inspection? A number of improvements have been made to the environment to provide better accommodation for the residents. This includes the purchase of new carpets to a number of bedrooms and both lounges, new bedroom and lounge furniture and a replacement floor to the kitchen and laundry. The laundry room walls have been plastered and a toilet door repaired. The outside of the premises is being painted. No new staff have been employed since the last inspection however all staff now have a CRB (Criminal Record Bureau) disclosure on file which helps ensure the safety of the residents. Photographs are taken for the purposes of identification for staff and residents. Staff are receiving mandatory training in safe working practice areas. For example, moving and handling, first aid, infection control and food hygiene. The training programme also includes abuse awareness and medicine management. This ensures staff have the skills and knowledge to provide the necessary care and support to the residents. The health and safety of the residents is now being better monitored by the provision of thermostically-controlled valves to the radiators and window restrictors to windows above ground height. A member of the senior management team conducts a monthly formal visit to the home and a report is then compiled of their findings. The reports were available at the home for the purpose of inspection. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents had been provided with a contract that included details of the service. Residents were admitted following an assessment so that the staff are able to ensure that care needs could be met. EVIDENCE: The care files seen had resident contracts which stated terms and conditions of residency and information regarding what the fee includes. These are given out following a six week trial period, which gives residents sufficient time to decide whether to take up permanent residency. The manager completes a full assessment of need for each resident admitted. The assessments seen had been completed prior to the resident arriving at the home. New assessment documentation is now in place and the assessments provided good detail of the resident’s health and social care requirements. They covered areas such as, mobility, sight, continence, hearing, dental and personal care, communication, social background and diet, past and current medical history was noted and also any medication that the resident had been Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 10 prescribed. Care management assessments from social services and letters from hospital were also on file to help provide a detailed background history of the resident. A resident said, “The staff were very nice when I arrived and have got to know me well.” The reason why a resident required care in the home had been recorded. This helps to establish the resident’ understanding of why the care and support is needed. Religious beliefs had bee noted thus enabling residents to continue to practice with their chosen faith. Standard 6 was not inspected, as intermediate care is not provided at the home. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recording systems of medicine administration must improve to help protect the welfare of the residents. Residents were observed to be treated in a respectful manner. EVIDENCE: As part of the case tracking process three resident care files were examined for residents who had recently been admitted. An individual plan of care was available in each file and the information had been collated from the care needs’ assessment and by getting to know the resident. Discussion with the manager and staff confirmed a good knowledge of each resident’s care and social needs. New care documents are now in place and the resident care plans identified a number of health and social care needs, for example, mobility, diet, continence, communication, skin care, medicines, and relevant medical and social history. A person centred plan of care gave a good overview of the resident’s health care needs to ensure good outcome for them. The care plans gave the staff information as to what the resident could do for themselves and what level of support they needed. The information evidenced a review date Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 12 however the care review should be recorded in more detail as it is an evaluation of the care over a period of time and should reflect any change. The staff looked at and they recorded whether or not there was any risk in relation to the residents developing pressure sores and also if they were at risk due to problems associated with eating and drinking, falls or mobility. A care plan was seen for a resident who required specialist equipment and a risk assessment was completed at the time of the inspection to support the care and identify any risks involved. Residents have aids and equipment to help them with daily living, for example, wheelchairs, walking sticks, walking frames, raised toilet seats and hand rails. A social services care file contained a plan of care to support the staff at the home. Residents had been weighed to monitor any weight gain or loss and a resident said the staff always kept an eye and on what they ate to ensure they kept well. No resident at this time required special care in relation to his or her cultural or religious beliefs. Care plans regarding sexuality did not always contain any detail and this was discussed in relation to recording information regarding appearance, general well being, beliefs and values. The manager stated that she would look at this as a training exercise for staff to help them have a better understanding of the various strands of equality and diversity. Staff had completed a care record, which gave a report of the care and support provided in accordance with the plan of care. Those seen reflected current care and social arrangements. Evidence was seen of appointments from outside health professionals and medical appointments made on behalf of the residents. A visit by a community matron had been recorded in one care file. It was evident that staff were aware of the importance of contacting the relevant person if external help was needed. This helps to ensure the resident keeps well. A resident reported, “I can always speak to somebody about my illness or how I am feeling.” No residents were currently receiving care from district nurses however if their clinical input was required then they would be called in to help the staff. Comments from residents and relatives regarding the care included: “Very good indeed” (relative) “I have no concerns about the care as we speak” (relative) “The girls work hard” (resident) “The staff are fabulous, cannot say any more really” (resident) “The staff are very good and the family and I are always informed even on the slightest subjects” (relative) “I am pleased with the care received” (resident) “I can have a bath at any time, I just have to ask” (resident) Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 13 Residents receive medicines from blister packs and these were kept locked in a trolley in a locked clinical room. A number of medicine charts were examined and these showed that the medicines were being administered by the staff according to the prescription. A sample of medicines was counted and compared with the records to check that they were given at the prescribed dose. The date medicines had been received in the building was recorded however the quantity received and staff signature responsible for their receipt had not been written on the medicine chart. This is required to ensure an audit (check) of the medicines can be undertaken at any time. A senior carer carries out visual check to make sure that medicines are handled in accordance with correct procedures. This check should be recorded to evidence that medicines are stored, handled and administered safely. Arrangements were in place for the safe disposal of unwanted (waste) medicines. Staff had received training in medicine awareness and it is good practice for the manager to complete a competency assessment to ensure all staff have the skills and knowledge for medicine administration. The manager is aware that risk management is required for medicines administered orally. A number of residents had requested to administer their own inhalers (for chest conditions) when required and a risk assessment for this practice was completed at the time of the inspection with a plan of care. Two staff signatures for checking and administering the medicine Temazepam has now been instigated as this is a medicine that is liable to misuse and this provides a further safety check. Residents and relatives said that the staff were polite and helpful. This was observed during the day. Domestic staff were seen to knock on bedroom doors before entering and residents were well dressed, clean and appeared at ease when in the company of the staff. A relative said, ”The staff are always polite and happy.” A resident had requested a male carer to assist with personal care. Their request had been written in the plan of care and had been respected. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were able to choose how they wish to spend their day and to join in with activities. Residents were served well-balanced meals to meet their nutritional needs. EVIDENCE: There was a friendly, relaxed atmosphere It was evident that the staff knew each resident well and had a good knowledge of individual need in relation to meals, assistance with personal care, family back ground and social interests. The resident’s preferred routine is discussed on admission, for example, time of retiring or getting up in the morning and also their food preferences. A resident said that they preferred to stay in their room with the visitors rather than sitting in the lounges. Staff interviewed were aware of this and respected this wish. The majority of residents choose to come to the dining room for lunch and enjoy getting together at this time. The cook was talking with the residents as to what they would like for breakfast and also what was on the menu for lunch. The manager offers an informal social programme and residents interviewed said this was what they wanted. Fund raising events take place with raffles and the residents are encouraged to take part. A staff member said that softball Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 15 exercise and musical entertainment were popular with the residents. An entertainer is arranged every three months. A resident said they enjoy the music and also going out at the weekends to visit family. Visitors were made welcome by the staff and offered refreshments. A relative said, “You could not have a better home.” Advocate details were recorded in care files along side family details. Work was being conducted at the time of the inspection to lay a new kitchen and laundry floor. Residents had been advised of the disruption and change in menu to accommodate the workmen. A check of the stores showed that there was plenty of fresh, frozen and dry goods to cook appetising meals and the menu offered a choice of hot and cold foods three times a day. Snacks at other times were available. A number of residents have cooked breakfasts, which were described as being “Tasty”. A relative said that birthday cakes are always made. Other comments regarding the meals included: “The cook makes everything from scratch and its very good” (relative) “Very good meals, it is always cooked nicely” (resident) “We talk to the cook about what we want on the menu” (resident) The dining room tables had been laid for lunch and the menu for week number two was on display in the main hall. The menu did not show an alternative choice at lunchtime however residents interviewed confirmed that they could choose something else if they preferred. Staff were seen to help serving meals in a polite, unhurried manner. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were confident their complaints would be listened to. Staff had been provided with good information as to what abuse is, thereby reducing the possible risk of harm to residents. EVIDENCE: The complaint policy and procedure was viewed and details of these were also provided in the Service User Guide (brochure on the home). A resident handbook also gave details of what to do should a resident wish to raise a concern. The AQAA stated that no complaints have been received since the last key inspection. One anonymous complaint received by the Commission regarding the safe transfer of residents was dealt with to the satisfaction of all parties. A resident interviewed said they knew who to talk to if unhappy and would talk freely with the staff. The manager confirmed that a complaint log would be completed should a complaint be received ‘in house’. Staff have access to adult protection procedures and this includes local guidelines, which should be followed to report an alleged incident. Staff interviewed said they receive abuse awareness training and there was a record of course dates in staff files examined. There have been no adult protection referrals and police checks are undertaken for all staff employed. This helps protect the residents. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,23,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Improvements have been made to provide more comfortable, clean accommodation. EVIDENCE: Since the last inspection the owner has instigated a good programme of decoration and this includes laying new carpets (in a number of bedrooms and both lounges), the purchase of new bedroom and lounge furniture and repair work to the laundry room. A new kitchen and laundry room floor was also being laid at the time of the inspection. The home appeared brighter and cleaner and plans are in place to replace the dining room carpet. Painting to the exterior of the premises will be completed once the weather improves. The garden is going to be re turfed which the residents will benefit from during the summer. Residents interviewed said their rooms were cleaned each day and kept tidy. A resident reported, “I have everything I need in my room and do not want anything else.” A resident has their own fridge and other bedrooms seen Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 18 showed that residents had brought items in from home to make their rooms feel ‘homely’. The provision of a call bell enables residents to call for assistance. One bedroom was in need of new wallpaper due to general wear and tear and a bedside cabinet needed a new handle, this was brought to the manager’s attention to rectify. Bedside cabinets had locks, which residents could use to store things safely. The AQAA states that curtains and bedding is new in all bedrooms. Window restrictors are now in place to ensure windows do not open too wide and the radiators had thermostatically controlled valves to regulate the heat. These measures help keep residents safe. The laundry room was tidy and clean. Staff have access to an infection control policy and gloves and aprons were plentiful. Clothes were returned to residents in new individual baskets. Bathrooms seen were clean and odour free and special bathing equipment enables the residents to bathe comfortably and safely. Emergency lighting is provided throughout the building and the hot water to the baths is regulated to ensure it is delivered to a safe temperature. Both these are checked regularly to ensure the safety of the residents. Records seen were satisfactory. A maintenance person is employed to carry out every day jobs and repair work to help keep the home in a good state of repair. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents received care and support from trained staff who were recruited correctly. EVIDENCE: The staffing rota showed that sufficient numbers of staff were on duty to provide care and support to the residents. A good team of staff support the manager and this includes a number of staff who are appointed a senior carer position. At the time of the inspection the manager was on duty with a senior carer, two care staff, cook, maintenance person and two domestics. The care staff help with laundry duties. The staffing structure provides an on call system by the manager and/or senior staff provides support to the staff on duty. Staff receive a hand over at each shift and at this time the needs of the residents are discussed. Staff made the following comments regarding the service: I am always given plenty of information regarding the residents I care for” “The service looks after the needs of each individual resident very much” No new staff have been employed since the last key inspection however staff files viewed evidenced completed application forms, police checks, health declaration statements and references. The files also showed good training records for courses attended by staff with evidence of certificates of attainment. Courses included, moving and handling, infection control, first aid, Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 20 food hygiene and abuse awareness. The manager has instigated an ongoing training programme and staff who have not attended health and safety will do this so later this year. Staff have also received diabetic training and are the manger is looking to provide training in oxygen therapy. A staff member interviewed said the training was arranged regularly and that when she started working at the home the manager asked for references, a police check and also arranged an induction. An induction makes sure new staff understand what is expected of them and that residents are cared for properly and safely. The Skills for Care induction standards are now available on disc and written format for new staff. Residents and relatives made the following comments regarding the staff: “They are very helpful” (relative) “Staff are attentive (relative) “The staff are very good (relative) “Fabulous staff” (resident) Very good indeed” (resident) NVQ (National Vocation Qualifications) at Level 2 and Level 3 are ongoing for the staff and the manager confirmed that over 50 staff have achieved a qualification at this level. NVQ certificates were not available in all staff files seen. These should be brought in by the staff to evidence their achievements. Two staff members interviewed confirmed what level of NVQ they had completed. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the service was effective and current practices and procedures ensure the safety and wellbeing of the residents. EVIDENCE: Mrs Jones is the registered manager and has completed NVQ Level 4 in Management and a bullet proof management course. Mrs Jones undertakes mandatory training with staff and also training in medicines awareness. Mrs Jones has many years experience caring for older people and keeps herself updated with current practices. Staff interviewed were complimentary regarding her management skills and they said they could talk to Mrs Jones at any time. Mrs Jones works supernumerary to assist with completion of managerial duties and has worked hard to improve the service to benefit the residents and staff. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 22 Mrs Jones’s name appears on the staffing rota however this does not show the hours she works each day. The staffing rota should include this information so that residents, staff and relatives are aware of when she is available and for maintaining an accurate record of people in the building in the event of a fire. The AQAA provided information on the service. Included in this document was details of how the manager monitors the overall service. The views of the residents and relatives have been sought by the completion of questionnaires. This quality assurance process gives the manager feedback as to whether people are satisfied with the care provision. The last ones were sent out in November 2007 and the results collated as part of an external quality award. Feedback from these and the Commission’s ‘Have Your Say’ Surveys was positive. Residents can take part in meetings and a resident handbook recorded the date of the last meeting and the agenda. A resident said the meetings are held often. A staff member interviewed said that staff meetings are also arranged and that they receive supervision from the manager. Staff supervision was not assessed at this inspection however staff interviewed said they meet with the manager to look at their training and staff development. The owner’s daughter conducts monthly visits as she has managerial input in to the home. A written report was available from a visit in February 2008 and this gave good information regarding the service at that time. Policies and procedures were available for the staff and the manager is now in the process of reviewing them to ensure the information is in line with current practice. Policies seen included, fire prevention, relationships/sexuality, privacy and dignity, recruitment, abuse, infection control and food hygiene. Residents are encouraged to look after their own finances however the manager was holding monies for a number of them. Records seen were maintained to a satisfactory standard to protect residents’ financial interests. The AQAA provided details of the maintenance of equipment and services within the home. Spot check of the gas, electric, fire prevention, moving and handling equipment, portable appliances and control of Legionella showed evidence of safety certificates. Staff receive fire prevention training ‘in house’. The manager undertakes the training with the staff on duty, at staff meetings and staff supervision. A recent visit by the fire brigade resulted in work needed to the fire doors; this is now being done. A fire risk assessment of the premises was seen and fire alarms were being tested each week. All these measures help ensure the ongoing safety of the residents and staff. If a resident suffers an accident then the incident is reported in a formal accident book. A record seen showed the nature of the accident and treatment Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 23 needed. Recording of accidents helps the staff to monitor the level of care and support each resident will need. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 24 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 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 X 3 X 3 3 Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 25 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 13(2) Requirement Records of medicines received into the home must include evidence of staff signature for their receipt and date of receipt to provide a clear audit trail. This will help ensure medicines are being administered correctly. Timescale for action 07/06/08 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 The evaluation of a resident care plan should be completed in detail to evidence the care given over a period of time. Equality and diversity should be addressed in more detail within the resident assessment and care planning process. Recommendations are made regarding the home’s safe handling, storage, administration and disposal of medicines that will further protect the residents: A list should be kept of staff signatures for those staff responsible for administering medicines to residents. A competency assessment should be completed for staff who administer medicines to residents. DS0000005377.V360548.R01.S.doc Version 5.2 Page 26 2. OP9 Hawthorne Lodge 3. OP19 4. OP31 A record should be kept of the monthly check of medicines procedures in the home. Date of medicines received in the building should be entered on the medicine charts and along with a staff signature for the staff member responsible for their receipt. The wallpaper should be replaced in the bedroom identified at the time of the inspection. The bedside cabinet identified at the time of the inspection should be repaired. The manager’s hours should be evidenced on the staffing rota. Hawthorne Lodge DS0000005377.V360548.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Regional Contact Team Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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.V360548.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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