Inspection on 06/02/06 for Hawthorne Manor

This inspection was carried out on 6th February 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 Manor 05/02/07

Hawthorne Manor 15/08/05

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 Announced Inspection 6th February 2006 10:00 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hawthorn Manor Address 369 Maidstone Road Gillingham Kent ME8 0HX 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) 01634 263803 Mr Richard Michael Radzik Mrs Stephaneie Jane Radzik Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th August 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 DS0000028876.V273870.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection under the terms of the Care Standards Act 2000 and took place on the 6th February 2006 between 10.00 and 15.00. One inspector was in the home and the main focus of the inspection was on the progress of the home in meeting with requirements and recommendations made at the last inspection, the general environment and the well being of the residents. During the inspection documentation and records were read. 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. The overall outcome was that the residents enjoyed a good quality of life and were well cared for by caring and competent staff. What the service does well: What has improved since the last inspection? The home has maintained the high standards noted at the last inspection. The home has introduced a new method of storing medication, which has proved successful. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1-6 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: These standards were assessed as met at the last inspection. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 8, 9, 10 Health needs are met and residents benefit from having full access to all professional health care services as required. The residents’ welfare is protected by the home’s policy and procedures with regard to the handling and administration of medication. Residents are treated with respect and their right to privacy is upheld. EVIDENCE: 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 intervention measures to minimise the risk of pressure sores. The home had change the way it administered medication to residents with each individual’s medication being stored in a locked, specifically designated cupboard in each individual’s bedroom. Senior staff visited each resident in their room to administer their medication. This system appeared to work well for this home and both staff and residents were happy with this arrangement. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 10 The home obtained its supplies from the pharmacist next door to the home. The home should invest in a medical fridge for the safe storage of liquids medications. Also care must be taken with regards to the temperature of eye drops upon actual administration. Evidence was found that eye drops that should be administered at room temperature were actually being given straight from the fridge. The written instructions on each pack must be read and acted upon. It is important to note that some eye drops need to remain in the fridge after opening and some kept at room temperature after opening. It was also advised that medication should be counted in on arrival to ensure an accurate audit can be completed at any given time. Regular audits should become part of the process for the storage of medications. The home did not have any controlled drugs on the premises. All Staff who administered medication had completed a recognised course on the Safe Administration of Medication. All of the residents spoken with felt they were well treated and that staff respected their dignity and privacy at all times. All said they felt safe and secure in the home. The remaining standards were assessed at the last inspection. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 11 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): 12-15 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. 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 DS0000028876.V273870.R01.S.doc Version 5.1 Page 12 Comments regarding the food were generally positive and many said they enjoyed the variety and the home cooking. 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. A menu board was seen. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 13 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): 16-18 Residents benefit from robust adult protection policies and procedures that ensure they are protected from abuse. The home has a clear complaints procedure and residents and relatives are aware of how to complain. Residents benefit from postal voting if required. EVIDENCE: The home had a comprehensive complaints policy and procedure, which clearly identified timescales for responding to written complaints. The senior carer stated that all issues were taken seriously and that problems were normally dealt with informally before it became necessary to use the formal complaints system. The home had adopted the revised Kent and Medway Multi Agency Adult Protection Policy, Protocols and Guidelines and staff had been trained in the protection of adults. All residents were registered for postal voting. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 14 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): 19-26 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. The rear garden and patio areas were pleasant and contained a safe area in which to enjoy summer weather. The home complied with the requirements of the local fire service and the environmental health department. The furnishings throughout the home were of good quality and domestic in nature. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 15 All of the rooms viewed had a call system in place and emergency lighting was provided throughout the home. 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. As recommended in the last report 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 was advised that non-powdered latex or vinyl gloves are used in accordance with the guidelines issued by the Kent and Medway Community Infection Control Guidelines. Non-powdered/latex free gloves should be available for any staff members with confirmed allergies. The Proprietor did state that he was still using up existing supplies before reordering the more appropriate ones. On the day of the inspection the homes was very clean and had no offensive odours. Some radiators in the original section of the home were not guarded or had guaranteed low temperature surfaces. This needs to be addressed as part of a planned maintenance programme with a definite timescale for completion. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 16 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 residents benefit from being cared for by staff who have a good understanding of their needs. Residents do not have the benefit of being cared for by fully trained staff. Extra night staff would ensure the home is sufficiently staffed. Residents are protected by robust recruitment procedures. EVIDENCE: The number of staffing hours confirmed by the proprietors indicated that according to the guidance produced by the Residential Forum the home was understaffed by approximately 50 hours per week. The home employed one waking night staff; the proprietor slept at the home at night six nights and was classed as the sleeping night staff. It will be a requirement that two night staff be employed to ensure the health and safety of all of the residents. The home has 35 residents and with the layout of the home, two staff need to be employed. When the extra night staff is employed the home should meet the staffing hours required. All of the staff had individual training records and an overall training matrix was discussed with the management team. It was suggested that an overall matrix would enable the management team to identify future training plans. Six of the sixteen care staff had obtained NVQ level 2 or above, this was 37.5 . The home must encourage more staff to complete NVQ to level to Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 17 ensure that a minimum of 50 of staff are qualified as required by standard 28, Regulation 18 (1)(a)-(c). The home did not have a specific written recruitment and selection policy but did have a copy of a Kroner policy, which it hoped to adopt. The procedure used was discussed and met with all of the requirements of sound practise. All staff completed an induction course during the first six weeks of employment. The proprietors confirmed they had recently joined the Medway Workforce Development Partnership. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31-38 The residents benefit from having a manager who has a clear development plan and vision for the home, which she effectively communicates to the residents, staff and relatives. The residents also benefit from having a manager who is well supported by the senior staff in providing leadership throughout the home and from staff who demonstrate an awareness of their roles and responsibilities. Residents do not benefit from having staff who receive regular supervision. Sound financial procedures protect residents. Current arrangements were not sufficient to fully protect the health, safety and welfare of residents and staff. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 19 EVIDENCE: Mrs Radzik had completed her National Vocational Qualification level four in both Management and Care and had the necessary experience to manage the home and to meet its stated purpose and aims and objectives. The atmosphere in the home was very positive and relaxed and staff confirmed that the management approach of the home created an open, positive and inclusive atmosphere. Staff stated that they felt well supported and fully involved with the home. The home is required to have an effective quality assurance and quality monitoring system in place to ensure they seek the views of the residents and other stakeholders to ensure it is meeting the aims and objectives and statement of purpose of the home. Discussion took place as how to achieve meeting this standard and the proprietors confirmed work would start soon to ensure this standard is fully met. Advice was given as how this would best be achieved. The home endeavours not to deal with residents’ personal monies and prefer families to take on this role. Staff supervision is an area that would improve from a more structured approach, some supervision is happening but not always very regularly and not always recorded. The management team confirmed that if requested all residents could have full access to their individual records. Records were held in a secure way and were up to date and in good order. Records were viewed regarding the maintenance of equipment etc. A few areas of concern were noted and these included the lack of Portable Appliance Testing (PAT) certificates and the lack of servicing for the bath hoist. The Stannah chair lift was later confirmed as being serviced in September 2005. The majority of the staff had received Fire Awareness training although some staff had not actually practised the fire drill. It was recommended that all staff complete a fire drill and suitable records to confirm this are maintained. A fire risk assessment had been approved by the local Fire Officer in January 2006. The home did not have an official accident book and was advised to obtain one. Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 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 3 18 3 4 3 3 3 3 3 3 3 STAFFING Standard No Score 27 2 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 1 3 3 2 3 2 Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 21 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 OP27 Regulation 18(1)(a) (3)(a)(b) Requirement Timescale for action 31/03/06 2. OP25 13(4)(a) (c) 3. OP33 24(1)(a) (b) (2)(3) The registered person shall, having regard to the size of the care home, the statement of purpose and the number and needs of the service users, ensure that at all times suitably qualified, competent and experienced persons are working in the home in that there are two waking night staff (27.5). Action plan required. The registered person shall 31/03/06 ensure that all parts of the home to which service users have access are so far as reasonably practicable free from hazards to their safety in that all radiators are guarded throughout the home. Action plan required. 31/03/06 The registered person shall establish and maintain a system for effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. DS0000028876.V273870.R01.S.doc Version 5.1 Hawthorn Manor Page 22 4. OP38 23(c) 5. OP28 18(1)(a)(c) Action plan required. The registered person shall ensure so far as is reasonably practicable the health, safety and welfare of service users and staff in that the bath hoist is regularly serviced and that Portable Appliance Testing (PAT) is undertaken. Completed by March 31st 2006. The registered person shall ensure a minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent). Action plan required. 31/03/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP26 Good Practice Recommendations 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 resident wishes regarding terminal care and death be recorded on the individuals care plan. It is recommended that regular and recorded supervision be undertaken at least six times a year for all staff. It is recommended that paper towels and liquid soap be provided in all of the toilets to ensure good infection control procedures. It is recommended that all staff complete an actual fire drill. This should not include evacuation of residents. 2. 3. 4 5 6 OP26 OP11 OP36 OP26 OP38 Hawthorn Manor DS0000028876.V273870.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Maidstone Local Office The Oast Hermitage Court Hermitage Lane Maidstone 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 DS0000028876.V273870.R01.S.doc Version 5.1 Page 24 - 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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