Inspection on 15/08/05 for Hawthorne Manor

This inspection was carried out on 15th August 2005.

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

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

Other inspections for this house

Hawthorne Manor 05/02/07

Hawthorne Manor 06/02/06

Hawthorne Manor 29/03/05

Hawthorne Manor 23/02/05

Similar services:

The Shelley

Springfield House

Sutton Lodge Nursing Home

St Helier`s Residential Hotel

St Joseph`s

Ridgemount

Wingham Court

Old Hastings House

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

CARE HOMES FOR OLDER PEOPLE Hawthorn Manor 369 Maidstone Road Gillingham Kent ME8 0HX Lead Inspector Sue McGrath Unannounced 15 August 2005 9.30am 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 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 Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hawthorn Manor Address 369 Maidstone Road Gillingham Kent ME8 0HX 01634 263803 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Mr Richard Michael Radzik Mrs Stephaneie Jane Radzik Care Home 37 Category(ies) of OP Old Age - 37 registration, with number of places Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 29 March 2005 Brief Description of the Service: Hawthorn Manor offers accommodation in a detached property, situated in a residential area close to local shops and on a bus route. Rainham town centre is approximately 2 miles away. Mr and Mrs Radzik (Proprietors) oversee the daily management and running of the home. The home is registered for 37 older people; there are 33 single bedrooms and 2 double rooms within the home. The home caters for low to medium dependency residents. The home has ample off road parking and a large pleasant rear garden and patio area. Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place on the 15th August 2005. One inspector was in the home and the main focus of the inspection was on the progress of the home in meeting with requirements made at the last inspection, the general environment and the well being of the residents. During the inspection documentation and records were read, including care plans. A tour of the building was undertaken and many of the residents and some visiting family members/friends were spoken to. Time was also spent talking to staff and members of the management team. What the service does well: What has improved since the last inspection? What they could do better: Advice is to be obtained from the Commission’s Pharmacy Inspector to improve the system for the administration of medication. Residents are not in any danger but some improvements could be made. Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 6 The home’s Statement of Purpose needs to be separated form the Contract of Terms and Conditions and should include all the information required under Schedule 1 of the Care Homes Regulations 2001. Access to the new wing would be improved if handrails were fitted, particularly to the stairs. Several residents said that they never know what is for dinner, it is recommended that menus be displayed, so that residents know what they are having at mealtimes. Whilst the pre-assessment procedure is robust, the home is reminded that it is not registered for residents who have been diagnosed of dementia and must not admit any such residents. 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 Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 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 standard(s) 1,2,3,4,5,6 Prospective residents are provided with the information they need to make an informed choice about moving into the home. Residents benefit from a comprehensive assessment of their needs prior to moving into the home to ensure their assessed needs can be met. Residents and families also benefit from the opportunity to visit the home prior to admission to assess the quality, facilities and suitability of the service. EVIDENCE: The owners had merged the Statement of Purpose, Service User Guide and Terms and Conditions of Residence into one document. It is advised that these three documents be kept separate. The Statement of Purpose should cover all information as detailed in Schedule One of the Care Homes Regulations 2001. The above document was well presented. The Senior Carer described how residents were admitted and was able to evidence that full assessments do take place prior to admission. Relatives spoken to confirmed that this was the normal procedure and that they had been fully involved in the admission to the home of their loved ones. All Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 9 residents had a month’s trial, but this could be extended, if required. A further review would be carried out at the end of the month to ensure the resident is happy to remain and the home was able to meet the assessed needs of the resident. Future residents and their families can visit the home at any time to look around and to assess the quality and the facilities of the home. Day visits by the resident can be arranged if required. The home does not provide Intermediate care. Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 10 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 standard(s) 7,8,9,11 Residents benefit from having care plans that identify their individual needs and give clear guidance to staff. Care plans are regularly updated to ensure changes are recorded and acted upon. Health needs are met and service users benefit from having full access to all professional health care services as required. EVIDENCE: A selection of care plans were read and found to contain all the personal information required. The home had introduced a new system of recording daily notes and each area of care was given a score. This made case tracking difficult and the owners are asked to review this system. Risk assessments were seen on resident’s files, and should be reviewed when deterioration is evidenced in the monthly dependency scores. All of the residents were registered with a local GP and had full access to specialist medical, nursing, dental, chiropody and therapeutic services and care from hospitals and community health services according to need. Care practises regarding tissue viability were good and the staff had a good understanding of preventative and appropriate interventions measures to minimise the risk of pressure sores. Nutritional assessments were not being Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 11 carried out and advise was given on how to carry these out and the benefits this procedure would have on the welfare of the residents. Some of the care plans remain unsigned by the individual resident. The homes Administration of Medication was assessed and a few minor areas of concern were noted. The Commission’s Pharmacist is to arrange a visit to offer further advise. All Staff had completed the recognised course on the Administration of Medication. The home had space on the care plans to indicate residents wishes during any terminal illness or death, but these had not been completed in many cases. It was recognised that sometimes this subject can cause distress to residents, but the home must ensure that this information is obtained and documented. The home does have a policy on bereavement. Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14,15 Residents are supported to maintain contact with family and friends, which ensures they continue to receive stimulation and emotional support. The residents benefit from the appetising meals and balanced diet offered by the home and those service users requiring specialist diets are well catered for. EVIDENCE: During the course of the inspection mostly all of the residents were spoken to. Everybody appeared happy and content and spoke very highly of the staff and the care offered. Some residents commented that they enjoyed the freedom of having several areas to enjoy, including the patio area outside. Most of the residents appeared happy with the level of activities that were arranged, but some wanted more entertainers brought into the home. Residents stated they felt free to make decisions about how they spent their time. One resident stated that he was not allowed to use the lift on his own, but when discussed further, did agree that this was for his own safety. Residents confirmed that they could have visitors at any time and that they could go out with their relatives whenever they wished. Visitors from two different residents were spoken to and confirmed that they were always made welcomed and kept informed of any changes in their loved ones condition. Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 13 Comments regarding the food were generally positive, although no one knew what was for dinner that day. It is advised that menus be displayed on a daily basis as required by standard 15.7. Staff stated that a choice was always given at mealtimes. Residents confirmed that they were offered three meals a day and that they could have hot or cold drinks when they wished. The meals seen on the day looked wholesome and were well presented. Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 16,18 The home has robust adult protection policies and procedures to ensure that residents are protected from abuse. The home has a clear complaints procedure and service user and relatives are aware of how to complain. EVIDENCE: The home does have a comprehensive complaints policy and procedure, which clearly identifies timescales for responding to written complaints. The senior carer stated that all issues are taken seriously and that problems are normally dealt with informally before it becomes necessary to use the formal complaints system. The home has adopted the revised Kent and Medway Multi Agency Adult Protection Policy, Protocols and Guidelines. It will continue to be a requirement that all staff are trained in Adult Abuse procedures and that staff can easily access the policy and procedure. Staff spoken to had some awareness of the subject. Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,22,26 Residents benefit from living in a clean, safe, well-maintained environment and have safe access to comfortable indoor and outdoor communal areas. Service users are encouraged to maximise their independence by having access to the range of specialist equipment supplied by the home. EVIDENCE: The home is very well maintained and decorated to a high standard. The lounges provide safe and comfortable surroundings in which to relax and enjoy. Several bedrooms were viewed and were found to be clean, comfortable and well maintained. The new wing was extremely well decorated and most rooms had a lovely view over the gardens. It will be recommended that handrails be fitted in the new wing, particularly on the stairs. The rear garden and patio areas were pleasant and contained a safe area in which to enjoy the summer weather. The home complies with the requirements of the local fire service and the environmental health department. Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 16 The furnishings throughout the home were of good quality and domestic in nature. The lighting within the home was appropriate to the needs of the residents. All of the rooms viewed had a call system in place. The homes laundry was viewed and found to be fairly small with regard to the number of residents in the home. It is suggested that if the homes continues to develop, a new laundry room is designed. The existing laundry room could then be used as a medical room. The home needs to assess the method of cleaning commodes and if necessary take advise from the Infection Control Nurse as to whether a sluice is required. (26.6). Gloves and aprons were provided for staff. It is advised that nonpowdered latex or vinyl gloves are used in accordance with the guidelines issues by the Kent and Medway Community Infection Control Guidelines. Nonpowdered/latex free gloves should be available for any staff members with confirmed allergies. On the day of the inspection the homes was very clean and had no offensive odours. Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not inspected EVIDENCE: Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Not inspected EVIDENCE: Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 x 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION 4 3 x 3 x x x 3 STAFFING Standard No Score 27 x 28 x 29 x 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x x x x x x x Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 20 yes Are there any outstanding requirements from the last inspection? 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 OP18 Regulation 12 Requirement It is a requirement from this inspection that the adult protection procedures are made available to all staff and that appropriate training takes place. Timescale for action Action plan by September 26th 2005 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. 5. 6. Refer to Standard OP 22.3 OP 26.5 OP 26.6 OP1 OP11 OP 3 Good Practice Recommendations It is recommended that hand rails be fitted in the new wing corridors It is recommended that non-powdered latex or vinyl gloves are used in accordance with the guidelines issues by the Kent and Medway Community Infection Control Guidelines It is recommended that advise is sought from the Infection Control Nurse as to whether a sluice is required. It is recommended that The Service User Guide, The Statement of Purpose and Contract of Terms and Conditions are seperated into three documents. t is recommended that resident wishes regarding terminal care and death are recorded on the individuals care plan. It is recommend that care plans are drawn up with the involvement of the service user, recorded in a style accessible to the service user; agreed and signed by the service user whenever capable and/or representative . H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 21 Hawthorn Manor Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 22 Commission for Social Care Inspection The Oast Hermitage Court Hermitage Lane Maidstone Kent. ME16 9NT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hawthorn Manor H56-H06 S28876 Hawthorn Manor V243541 150805 Stage 4.doc Version 1.40 Page 23 - 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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