Inspection on 08/12/05 for Hawthorns (EVESHAM), The

This inspection was carried out on 8th December 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

Hawthorns (EVESHAM), The 10/10/08

Hawthorns (EVESHAM), The 21/11/06

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 Chris Potter Unannounced Inspection 8th December 2005 14:00 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 The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 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.V272076.R01.S.doc Version 5.0 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 Care Home 46 Category(ies) of Dementia - over 65 years of age (40), Mental registration, with number disorder, excluding learning disability or of places dementia (6) The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. The home may also accommodate six service users from the age of forty with mental disorder and associated physical disability. The home is primarily for older people over 65 years with a dementia illness, but may also accommodate people over 55 years with a dementia illnes The home may also accommodate people with a dementia illness who have an associated physical disability. 1st August 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.V272076.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over four hours for part of the day on the 8th December 2005. A part tour of the premises took place, care plans, staff records and health and safety records were checked. Four staff and several residents were spoken to during the visit. What the service does well: What has improved since the last inspection? What they could do better: The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 6 The proposed manager should formalise a staff supervision program for all staff. This should include all aspects of practice, philosophy of care in the home and career development needs. 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 (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 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.V272076.R01.S.doc Version 5.0 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): 2,3,4 and 5 All residents are appropriately assessed prior to moving into the home, and provided with appropriate information to assist them in making their choice. EVIDENCE: A sample of three residents care records was reviewed which included their pre-admission assessment. The acting manager or registered nurse visits the potential resident and completes the pre-admission assessment. The assessment is based on the resident’s health problems and their physical needs. This assists the acting manager in ensuring the home can fully meet their needs. The pre-admission assessment then forms the basis of the residents care documentation. The home offers respite care, this further assists the home to understand the resident and their family needs. This assists should the need arise for them to require permanent care at the home. The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 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): 7,8,9 Resident’s care documentation reflects their health care needs. The homes Medication procedure was being followed. EVIDENCE: Since the last inspection the residents care documentation has further improved. The documentation appeared to reflect the care needs of the residents. Appropriate risk assessments were in place and regular review being completed by the nurses. Accident records showed that the home completes them appropriately. The manager completes a monthly audit of all accidents in the home, which is considered good practice. Since the last inspection the home has provided medication training for all registered nurses. The medication policy was being adhered and the requirements from the previous inspection actioned. The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 10 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): 13 and 15 The home provides a varied choice of meals catering for the residents’ likes, dislikes and special diets. EVIDENCE: The home encourages family and friends to visit. Details of the residents close family and friends are included in their care documentation. The home provides open visiting and provides facilities for them to make refreshments. The activities organiser continues to develop the social activities for the residents’. Records are maintained within the residents care documentation of their choices of social activities. The catering staff was well-organised and appropriate records and safety checks were being undertaken. The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 11 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 and 18 Complaints are handled appropriately. The home has a procedure for responding to any potential allegations of abuse. EVIDENCE: The home maintains detailed records of any complaint made, these records were available and showed that the homes procedure had been followed. The CSCI has received one complaint since the last inspection, this is currently being investigated by the home and the CSCI. Written policies and procedures are in place in order to ensure the protection of residents, which includes a whistle blowing policy. The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 12 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): 19,24 and 26 Investment into the home continues to maintain a high environmental standard, creating a comfortable and safe environment for those living there and visiting. EVIDENCE: The home provides a safe comfortable and well-maintained environment. Many bedrooms have been personalised by the resident, which further enhances their appearance. The home has four lounges, and four dining rooms. A passenger lift assists residents to access all areas of the home. The home has an ongoing program for routine maintenance and a system for checking safety aspects. The servicing of the fire alarm system was due, the last one being 04/11/05. The home is planning to develop a sensory garden for the residents next year. The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 13 All areas of the home were clean and tidy the management of odours was commended. The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 14 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 and 29 Staffing levels 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 39 residents. In addition to the nursing and care staff, there was also administration, ancillary, and catering staff to support the service provision. It was reassuring to observe that the home had completed the Christmas duty rota. The recruitment procedure was being followed appropriately. It was recommended that the company recruiting staff from overseas provide more recent references for the staff. One applicant’s references dated from 1999 and 2001. The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 15 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): 31,36 and 38 The proposed manager is ensuring the needs of the residents are met. Records and registers reviewed were available and up to date. EVIDENCE: The proposed manager is in the process of submitting an application for registration with the Commission. Staff were complimentary about the management approach and how the home continues to improve. The atmosphere in the home was relaxed and staff appeared competent in their roles. The staff are supervised in an informal manner, this should be formalised to include all aspects of practice, philosophy of care in the home and career development needs. The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 3 3 3 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X 4 X 3 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X X X X 2 X X The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 17 Are there any outstanding requirements from the last inspection? Yes 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 OP31 Regulation 8 Requirement A permanent manager must be appointed to the home, and application must be made to the Commission for registration. The home should develop a staff supervision program. This should include all aspects of practice, philosophy of care in the home and career development needs. Further formal training must be provided to staff regarding management of challenging behaviour. Timescale for action 31/01/06 2 OP36 18 01/04/06 3 OP36 18 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Hawthorns (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 18 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: 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 (EVESHAM) DS0000044062.V272076.R01.S.doc Version 5.0 Page 19 - 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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