Inspection on 01/08/05 for Hawthorns (EVESHAM), The

This inspection was carried out on 1st August 2005.

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

Other inspections for this house

Hawthorns (EVESHAM), The 10/10/08

Hawthorns (EVESHAM), The 21/11/06

Hawthorns (EVESHAM), The 08/12/05

Hawthorns (EVESHAM), The 20/01/05

Hawthorns (EVESHAM), The 08/07/04

Hawthorns (EVESHAM), The 18/03/04

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

CARE HOMES FOR OLDER PEOPLE THE HAWTHORNS Church Street Evesham Worcestershire WR11 1EP Lead Inspector Nick Richards Unannounced 01 August 2005 - 9:20 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. THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Hawthorns Address Church Street Evesham Worcestershire WR11 1EP 01386 444330 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) Shaw Healthcare Limited CRH 46 Dementia - over 65 Mental disorder 40 6 Category(ies) of DE(E) registration, with number MD of places THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 20 January 2005 Brief Description of the Service: The Hawthorns is a purpose built home, it was designed to meet the needs of service users with physical and mental disabilities. The home was registered on the 29th September 2003 to accommodate 40 residents. In December 2003 the second phase of the homes registration was completed for an additional six residents. The home provides 24-hour nursing care to residents with a degree of mental illness and associated physical disabilities.The Hawthorns is part of the Shaw Healthcare (Homes) Limited - a major provider of care homes around the country. The responsible individual for The Hawthorns is Mr P J Nixey. The home is conveniently located in Evesham, which is convenient for the local facilities and visitors using public transport to access the home.The home provides limited car parking facilities for visitors and staff. The home is spacious, well facilitated, and accomodation is provided on three floors of the home (although the third-floor area is not, currently, used by residents. Access to the first floor area is through a central staircase or a central passenger lift. All bedrooms are single occupancy, with en-suite toilet and shower facilities. In addition the home provides lounges, dining rooms and specialist bathrooms for residents.There is provision for visitors to make refreshments, and an area is dedicated for visitors to sit with residents. A garden area is provided for residents to use when the weather permits. THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of 4 hours, and was carried out to assess how the home was addressing the many requirements from the previous inspection, and to establish how effective care was during the morning period. A tour of the premises took place and staff and care records were inspected. Six staff on duty and five of the residents were spoken to. Due to the nature of the conditions of the residents within the home, it was impossible to ascertain their opinion about the quality of service provided to them. However, opportunity was taken to observe care interactions and resident responses to the interactions. What the service does well: What has improved since the last inspection? Social care, staffing levels, training and development, as well as healthcare and healthcare management have all improved since the time of the previous inspection. Effective, temporary, management has been appointed to the home and this is helping to promote standards within the home. It is pleasing to note that residents’ quality of life has improved and the workforce is now more cohesive, settled and content. THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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. THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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 THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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) 2, 3 and 4. Good progress had been made to improve the admission procedure to ensure that there is a proper assessment prior to people moving into the home. This helps to ensure that care needs can be met. EVIDENCE: Individual records are kept for each of the residents, and inspection of the records for three residents had full assessment information recorded. Staff members on duty were spoken to, and knew about the care needs of the residents. Most residents in the home were unable to comment on the homes ability to meet their needs, due to memory loss problems. However, staff interaction and interventions with residents was observed, leading to the conclusion that the home could effectively meet the needs of people who can demonstrate some very challenging behaviour. Each care file had a comprehensive “Service Agreement” (or Contract), which had been countersigned by each resident’s next-of-kin and a home representative. One Service Agreement did not specify the room to be occupied, while all three Service Agreements did not specify the contact details for the Commission should the individual (or their representative) wish to make a complaint about the home to the Commission. While it is THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 Page 9 acknowledged that the documents examined were copy documents, opportunity should be taken to ensure that all Service Agreements contain the cited information. The home does not contract to provide intermediate care. Therefore Standard 6 is not applicable to the home. THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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 and 9. Significant progress has been made on improving arrangements to ensure that the health care needs of residents are identified and met. These improvements help to safeguard the health care needs of residents. There is a clear and consistent care planning system in place to adequately provide staff with the information they need to satisfactorily meet residents’ needs. The health needs of residents are well met with evidence of good multi-disciplinary working taking place on a regular basis. EVIDENCE: Individual plans of care are available, and progress has been made to ensure that all aspects of health, personal and social care needs are identified and planned for. Plans were detailed, up to date and had been regularly reviewed. Significant events in the home had been recorded, daily entries into case records had been made and entries available gave an indication of the actual care given. Staff were seen providing care sensitively and discretely to residents, and discussions with staff confirmed that they were aware of residents’ care needs, and how the care was to be provided. Nursing staff were observed administering medication to residents. Medication was administered safely and sensitively to ensure that the right medication THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 Page 11 was administered to the right person, at the right time and in the right dose – thereby promoting the safety and well-being of residents. The homes medication records were examined, and were, generally, being managed well. However, there were a few occasions when nursing staff had failed to record the administration of medication onto the medication charts, and when some medication that had been prescribed on a variable dose basis had been administered, nursing staff had, at times, failed to record the actual dose administered. This lapse in record keeping poses a potential risk to the health and safety of residents. THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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) 13 and 15. Meals are well managed, creative and provide daily variety and flexibility for people living in the home. Contact with family and friends was openly maintained. EVIDENCE: Menus were inspected and found to be balanced and interesting and mealtime arrangements are also flexible enough to accommodate individual preferences. Catering staff demonstrated a detailed knowledge and understanding of individual residents’ dietary preferences and requirements. Care staff were seen providing direct assistance to people with their breakfast in a sensitive and relaxed manner. Many residents were enjoying a cooked breakfast at the time of inspection. Lunch was offered as cauliflower cheese, with blancmange as a dessert. Residents who possessed swallowing difficulties were offered and enjoyed the same choice of food as residents who did not possess swallowing difficulties. During the inspection, some relatives were seen visiting people, and staff greeted visitors politely. THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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 standard(s) These Standards were not examined at the time of inspection. EVIDENCE: These Standards were not examined at the time of inspection. THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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 standard(s) 19, 20, 21, 22, 23, 24, 25 and 26. Investment within the home continues to ensure that a high environmental standard is maintained, creating a comfortable and safe environment for those living there and visiting. EVIDENCE: THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 Page 15 The bedrooms are all single occupancy with en-suite facilities. Communal toilets and bathrooms are available throughout the home. Separate lounge and dining room facilities are provided on each floor of the Home. Systems were in place for the management of infection control, and the home was clean, tidy and free from offensive odours. Each bedroom seen had been furnished with residents’ personal possessions, thereby generating ownership and a sense of autonomy for individuals. The standard of the environment within the home is good, providing residents with an attractive and homely place to live. Hot water temperatures have been risk assessed and had been regulated to prevent people being accidentally scalded when they have a bath, and radiators had been guarded and restricted to prevent people being accidentally burnt through intentional or unintentional contact All the windows located above first floor level had been restricted to prevent people from being injured through falling out of the windows (accidentally or deliberately). THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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 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) 27, 28, 29 and 30. Staffing levels and competencies are suitable to ensure that residents’ needs are identified and effectively met. EVIDENCE: There were suitable nursing and care staff on duty to provide care and support for the 34 people who were resident in the home at the time of inspection. In addition to nursing and care staff, there were also ancillary staff on duty to support service provision. During the visit, call bells were activated, and staff responded speedily to them. The duty rotas confirmed that the staffing levels were stable, with little evidence of staff being absent through short-term sickness. Training has been provided to staff, and includes infection control, first aid and moving and handling. Training was identified as a result of the needs of residents, to ensure that care delivered was appropriate to and in response to the needs of residents. A small number of staff had undertaken and completed National Vocational Qualification Level 2, and the homes management representative said that NVQ training had failed as a result of the training organisation allocated to the home failing to deliver the training necessary to ensure that 50 of carers are THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 Page 17 trained to NVQ level 2 (or equivalent) by 2005. The home was looking at accessing clinical training for nursing staff to include cannulation, venepuncture and male catheterisation. Although staff had received induction, which touched on the management of challenging behaviour, no specific training had yet been accessed. This is important given the unfortunate nature of some behaviours demonstrated by residents as a result of their short-term memory loss. Three staff files were examined, and documentation available confirmed that the home is operating a robust recruitment procedure to ensure the protection of vulnerable residents. THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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) 31, 32, 33, 36 and 38. Although there is clear leadership, guidance and direction to staff to ensure residents receive consistent care, resulting in practices that promote and safeguard the health, safety and welfare of the people using the service, the home has not had a permanent (registered) manager since its registration, and this can adversely impact on the continued stability of the home. EVIDENCE: Significant diligence and action has been undertaken to improve the quality of the service provided by the home since the time of the previous inspection. Staff commented that “things” have definitely improved since the time of the previous inspection. There is, and has not been a registered manager of the home since it was opened in 2003. The quality of care provided in a care home is strongly influenced by the calibre of the registered manager and their relationship with the registered provider of the home. Residents, and their next-of-kin, need the THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 Page 19 confidence to know that there is a permanent manager appointed to the home, who has passed the fitness test of the Commission – to ensure their appropriateness to manage a care service. Staff were being supervised in a positive manner. The home is undertaking regular quality assurance exercises on various aspects of the homes functioning to ensure that (a) quality is maintained and (b) to improve standards whenever possible – thereby enhancing residents’ quality of life and well-being. THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 3 x N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 x 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 1 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x 2 3 3 x x 3 x 3 THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 Page 21 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 9 Regulation 15 Requirement All medication administered to residents must be accurately recorded onto medication administration record charts. Arrangements must be made for staff to receive training that will enable a minimum of fifty per cent of care staff to attain a qualification at NVQ level 2 (or equivalent) by 2005. Further training must be provided to staff regarding the management of challenging behaviours. A permanent manager must be appointed to the home, and application must be made to the Commission for registration. Timescale for action Immediate and ongoing 31/12/05 2. 28 18 3. 28 18 30/10/05 4. 31 8 30/10/05 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 2 Good Practice Recommendations Service agreements should specify the room to be occupied and contact details for the CSCI. E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 Page 22 THE HAWTHORNS Commission for Social Care Inspection The Coach House John Comyn Drive Droitwich Road Worcester WR3 7NW 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 THE HAWTHORNS E52 S44062 Hawthorns (Evesham) V234467 010805.doc Version 1.30 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!