Inspection on 21/11/06 for Hawthorns (EVESHAM), The

This inspection was carried out on 21st November 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

Hawthorns (EVESHAM), The 10/10/08

Hawthorns (EVESHAM), The 08/12/05

Hawthorns (EVESHAM), The 01/08/05

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 (EVESHAM) Church Street Evesham Worcestershire WR11 1EP Lead Inspector N Richards Unannounced Inspection 21st November 2006 10:30 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 The Hawthorns (EVESHAM) DS0000044062.V319879.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. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hawthorns (EVESHAM) Address Church Street Evesham Worcestershire WR11 1EP 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) 01386 444330 01386 444331 The-Hawthorns@shaw-homes.co.uk Shaw healthcare Limited Mrs Rebecca Jane Faux Care Home 46 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (40), Physical disability (6) of places The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may also accommodate people with a dementia illness who have an associated physical disability. 8th December 2005 Date of last inspection 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 is registered to accommodate 46 residents. 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 accommodation is provided on three floors of the home (although the third-floor is not in use at the moment. All bedrooms are single occupancy, with en-suite toilet and shower facilities. In addition the home provides lounges, dining rooms and specialist bathrooms. 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 (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over a period of 4¼ hours, and was carried out to assess the home’s performance against key standards within the National Minimum Standards (Care Homes for Older People). A tour of the premises took place and staff and care records were inspected. 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 seek the opinion of residents’ relatives, and to observe care interactions and resident responses to the interactions. Since the time of the previous inspection, a new manager has been registered with the CSCI, a new deputy manager has been appointed and a six-bedded unit for younger adults with an acquired brain injury has been commissioned. At the time of inspection, the home was operating at 91 occupancy. The home charges fees ranging from £536.00 per week to £614.00 per week. The fees do not include costs for hairdressing, private chiropody and toiletries. 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 management has been appointed to the home and this is helping to promote quality standards within the home for those people using the service. Catering standards have improved considerably. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 6 It is pleasing to note that residents’ quality of life has improved and the workforce is now more cohesive, settled and content. 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. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 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 The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Positive effort has been made to maintain a robust 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 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. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 9 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. The home does not contract to provide intermediate care. Therefore Standard 6 is not applicable to the home. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Significant progress has been made on improving arrangements to ensure that the health care needs of residents are easily identified and effectively met. These improvements safeguard the health care needs of residents. There is a clear and consistent care planning system in place to adequately provide all staff with the information they need to satisfactorily meet residents’ needs. The health needs of residents are well met with evidence of good multidisciplinary 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 The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 11 care given. Staff were seen providing care sensitively and discretely to residents, and staff were clearly aware of residents’ care needs, and how the care was to be provided. Care records examined clearly demonstrated how the home had improved the healthcare state of several residents, thereby promoting independence. Feedback from relatives was overwhelmingly positive, with comments like “…impressed with high standard of equipment and staff caring for these people with special needs…I feel ***** is contented and cared for with feelings” (sic). Medication records were examined, and demonstrated positive and safe medication management within the home. Some residents had been successfully weaned off antipsychotic medication since having been admitted to the home. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 10, 11, 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. Meals are well managed, creative and provide daily variety and flexibility for people living in the home. Residents have opportunities to participate in leisure and recreational activities that meets their needs and expectations. Contact with family and friends is supported, and opportunities for residents to exercise choice over their lives has been maintained to enable them to maximise personal autonomy. EVIDENCE: Menus were inspected and found to be nutritionally balanced and interesting, and mealtime arrangements are also flexible enough to accommodate individual preferences. Catering staff demonstrated a wonderfully detailed knowledge and understanding of individual residents’ dietary preferences and requirements. The main meal on the day of inspection consisted of a choice between smoked haddock with cheese and chive sauce or cod. The chef is amply qualified and was a finalist in ”“Care Chef of the Year” - a national competition run by the publication “The Caring Times. Shortly after the The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 13 inspection, the registered manager advised the CSCI that the chef had won the title “Care Chef 2006”. Care staff were seen providing direct assistance to people with their lunch in a sensitive and relaxed manner. Many residents (approximately 75 ) enjoy a cooked breakfast during the morning. Residents who possessed swallowing difficulties were offered and enjoyed the same choice of food as residents who did not possess swallowing difficulties. Residents’ weight charts confirmed that residents were not losing weight unexpectedly, and that weights were stable. During the morning and afternoon periods, care staff provide residents with drinks and snacks. Care staff were seen providing direct assistance to people with their lunch in a sensitive, discreet and relaxed manner. Residents said that the dining facilities were suitable to their needs. Residents could choose to have their meals in their own rooms, in the dining area or in the lounges. During the inspection, some relatives were seen visiting people, and staff greeted visitors politely. Residents are able to receive visitors within the communal areas of the home, or in the comfort and privacy of their own rooms. The individual preferences of residents have been carefully sought, and the activities being undertaken reflect the preferences conveyed by the residents within the home. Since the time of the previous inspection, the home’s activities organiser had left the employ of the home, but a replacement had been recruited and was due to commence employment soon. In the (temporary) absence of an activities organiser, support workers were engaging residents in social, occupational and recreational activities. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Complaint management and adult protection within the home is effective to ensure resident safety is promoted. Complaints are handled objectively and relatives are confident that their concerns will be listened to, taken seriously and acted upon. A vulnerable adults procedure is available to ensure a proper response to any suspicion or allegation of abuse. EVIDENCE: The home has a simple and clear complaints procedure, and the complaint records indicate that this is followed. No complaints had been recorded since the time of the previous inspection. A copy of the complaints procedure was available to all residents, visitors and relatives. Relatives were confident that concerns could be raised with the home. The home manager responds to complaints at a grass-roots level, and this approach helps to ensure that concerns are addressed speedily and effectively. A procedure for responding to allegations of abuse is available, and mirrors Worcestershire’s multi-agency adult protection guidelines (which was available for reference purposes within the home). The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 15 Staff receive training in relation to the protection of vulnerable adults and the recognition of, and prevention of abuse. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 16 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): 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. 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 bedrooms are all single occupancy with en-suite facilities. Communal toilets and bathrooms are available throughout the home, and are easily accessible. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 17 Separate lounge and dining room facilities are provided on each floor of the Home, and systems are in place for the management of infection control. The home was clean, tidy and free from offensive odours. Relatives providing feedback were positive about the physical environment. One person said “(the) home is always first class and clean at all times”, while one resident made the comment “you could eat off the carpets”! 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). It was noted that several corridor areas within the home were looking worn and in need of replacement. Opportunity was taken to discuss this with the home’s regional manager, who advised that approval had been given for the carpet to be replaced. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 18 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): 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. Staffing levels and competencies are suitable to ensure that residents’ needs are readily identified and effectively met. EVIDENCE: There were suitable nursing and care staff on duty to provide care and support for the 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. Many staff had undertaken and completed National The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 19 Vocational Qualification Level 2. Staff were seen interacting with residents in a relaxed, informal and compassionate way. 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 (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35 and 38. Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. 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. EVIDENCE: The registered manager is competent and appropriately qualified and experienced to manage the service. Staff spoke very highly of her (giving her a mean average score of 85 (i.e. “what score would you give her out of 10?”), while one person said “(she) deserves a gold star”. Significant diligence and The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 21 action has been undertaken to maintain and enhance the positive quality of the service provided by the home since the time of the previous inspection. Relatives clearly expressed their opinion that the home was being run in the best interests of the residents. 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 registered manager effectively discharges her duty of care to ensure that the health and safety of residents and staff is maintained and maximised. The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 22 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 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 4 X 3 X 3 X X 3 The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 23 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Hawthorns (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Worcester Local Office Commission for Social Care Inspection The Coach House John Comyn Drive Perdiswell Park, Droitwich Road Worcester WR3 7NW National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 (EVESHAM) DS0000044062.V319879.R01.S.doc Version 5.2 Page 25 - 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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