Please wait

Please note that the information on this website is now out of date. It is planned that we will update and relaunch, but for now is of historical interest only and we suggest you visit cqc.org.uk

Inspection on 14/06/06 for Hawthorns Nursing Home

Also see our care home review for Hawthorns Nursing Home for more information

This inspection was carried out on 14th June 2006.

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.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

Service users and their relatives spoke positively about the manager and her team; One relative said "The manager is very good, she does everything that she can to make my mum comfortable" " The nurse manager is also very good" Another comment was "I like the way that staff, including kitchen and domestic staff, interact with the people living here" Another person said; "The standard of cleaning is very good, all the staff here work very hard" A needs assessment is completed for all service users prior to their admission. Trial visits are available, and short stay service users are enabled to return home. Care plans are in place for all service users and their health care needs are properly met. A safe system of medication is in place. Palliative care is offered with care and respect. Family and friends are actively involved in the running of the home, with an active and vocal "Friends of Hawthorns" group in place. Service users views are sought by way of satisfaction surveys. An enthusiastic and caring cook is on site to prepare fresh meals all day, and she consults directly with service users about their meal choices. Formal complaints are dealt with appropriately. The home is clean and hygienic. Service users monies are meticulously recorded. The health and safety of service users and staff are protected.

What has improved since the last inspection?

Several of the requirements and recommendations that relate to management and systems in the home have been addressed. Medication has been reviewed in terms of its delivery time and disposal of unused stocks are now properly disposed of. Care notes are held alongside medication records to assist administration. Duplicate keys for medication are now securely stored. A review of medication only taken when required has taken place. An updated medicine policy is in place. The care planning process has also been reviewed. Training in palliative care has taken place. The "Friends of Hawthorns group has gained strength, and a representative proprietor has attended a recent meeting. Some redecoration and renewals to the building have been undertaken. A training needs analysis for staff as individuals and the home as a whole has been undertaken. A recent survey of service user satisfaction has been undertaken. Staff appraisals and a system of staff supervision have been instigated.

What the care home could do better:

CARE HOMES FOR OLDER PEOPLE Hawthorns Nursing Home 270 Unthank Road Norwich Norfolk NR2 2AJ Lead Inspector Maggie Prettyman Unannounced Inspection 14th June 2006 11:15 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 Hawthorns Nursing Home DS0000044394.V300507.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. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorns Nursing Home Address 270 Unthank Road Norwich Norfolk NR2 2AJ 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) 01603 452302 Alphacare Services (UK) Ltd Position Vacant Care Home 28 Category(ies) of Old age, not falling within any other category registration, with number (28) of places Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Twenty-eight (28) Older People may be accommodated. Date of last inspection 6th December 2005 Brief Description of the Service: The Hawthorns Nursing Home is situated on the city boundary of Norwich. It is a converted Victorian house with a large extension to the rear of the premises. The home can accommodate 28 older people with nursing or/and care needs. The accommodation is on two floors and offers 5 double rooms and 18 single rooms some with en-suite facilities. The communal areas are on the ground floor, and there is a passenger lift to the first floor. There are garden areas to the front and rear of the property and off street parking to the side and front of the home. The range of weekly fees is £430 - £490 per week. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A single inspector undertook this unannounced key inspection over the course of 8 hours. Prior to inspection a number of feedback forms were received from service users, their relatives and friends and visiting members of the medical profession. The acting manager also completed a pre inspection questionnaire. The inspection comprised a thorough tour of the premises, inspection of staff and service user files, examination of records and procedures in the home and discussion with service users, their families and friends as well as the manager, some care and ancillary staff and one of the proprietors. Hawthorns is a homely and friendly place, where good standards of heath and personal care are provided. Service users needs are properly assessed prior to admission and continue to be reviewed and addressed during their stay. Good relationships are maintained with families and friends. Management, domestic and care staff are hard working and service users views are sought to ensure that the home is run for their benefit. This report contains a number of requirements and recommendations that often reflect on resources, staffing or environmental, available to the home. Discussion of these issues formed part of the feedback given to the representative proprietor, who assured the inspector that these matters will be addressed as a matter of priority. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Several of the requirements and recommendations that relate to management and systems in the home have been addressed. Medication has been reviewed in terms of its delivery time and disposal of unused stocks are now properly disposed of. Care notes are held alongside medication records to assist administration. Duplicate keys for medication are now securely stored. A review of medication only taken when required has taken place. An updated medicine policy is in place. The care planning process has also been reviewed. Training in palliative care has taken place. The “Friends of Hawthorns group has gained strength, and a representative proprietor has attended a recent meeting. Some redecoration and renewals to the building have been undertaken. A training needs analysis for staff as individuals and the home as a whole has been undertaken. A recent survey of service user satisfaction has been undertaken. Staff appraisals and a system of staff supervision have been instigated. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 7 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. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 8 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 Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 9 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): 3, 5 and 6 The overall quality outcome for these standards is good. No service user moves into the home without having their needs assessed and been assured that these will be met. Prospective service users and their relatives have an opportunity to visit and assess the quality, facilities and services of the home. Service users residing for intermediate care are helped to maximise their independence and return home. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 10 EVIDENCE: Examination of service users files demonstrated that a basic needs assessment is conducted by the home’s acting manager prior to their admission to the home. Information relating to social interests and hobbies is collated soon after admission. Discussion with service users and their relatives demonstrated that visits are welcomed prior to admission. One relative commented that it was the friendly atmosphere found in the home on this visit that influenced the decision to come to the home in preference to others. Discussion with the acting manager demonstrated that the home has helped several people by providing both respite and rehabilitative care that positively enabled people to return home. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 11 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, 10 and 11 The overall outcome for these standards is adequate 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 met, but some improvements in recording and monitoring should be made. Service users are mainly protected by the homes policies and procedures, but some improvements in recording and audit should be made. Service users generally feel that they are treated with respect and that 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. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 12 EVIDENCE: Inspection of service user plans found them to be detailed and containing appropriate risk assessments. The inspector noted that at times the writing can be difficult to read. It is recommended that staff completing records work to ensure that they are always legible. Discussion with a visiting GP, 5 response cards from GPs and other health care professionals and examination of care records demonstrates that health care needs are met by the home. Feedback from relative’s survey and individual discussion highlighted two areas of concern. Liquid refreshment is regularly available in the home, but at times service users may need more encouragement to drink. Two service users were found to have extremely fragile skin. Whilst appropriate risk assessment and care management notes are in place, no active investigation of how skin tears have occurred is made. It is recommended that staff encourage service users to access their drinks regularly. It is required that investigation of the cause of any skin tear is investigated so that further preventative action can be taken. Inspection of the treatment room and drug storage facilities demonstrated that medication is carefully stored, and that daily records are maintained. Since the last inspection several improvements to the systems and storage of medication have been made. The inspector found that some oral feeds were not named and dated, and that some omissions in recording administration had not been picked up. It is required that all oral feed bottles are named with the user and the date of opening noted. It is also required that medication recording is audited and errors or omissions investigated. Feedback from service user questionnaires and observation on the day of inspection demonstrated that the vast majority of interactions between care staff and service users is positive, polite and courteous There have been some incidents recently where staff relationships may have interfered with this positive atmosphere. One relative felt that care staff do not have enough information about peoples’ life history to enable them to be valued as a “whole” person with a Background of competencies and achievements. It is required that difficulties in staff relationships do not impinge on interaction with service users. It is recommended that more detailed personal histories are taken form those service users that wish, and shared with the care team that look after them. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 13 Feedback from relatives and friends of service users suggests that on occasion service users may be taken to their rooms without their express permission. It is recommended that the nurse on duty be informed by the care worker involved before any service user is taken to their room. Statistics from the pre inspection questionnaire and discussions with the acting manager demonstrate that the majority of service users choose to spend their final days in the home. Additional training in palliative care has recently been acquired by the home. Care protocols including ain relief are discussed with the service users GP. Relatives and friends are appropriately supported and remain with the service user as long as they wish. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 14 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, 13, 14 and 15 The overall quality outcome for these standards is good. Service users do not always find that the lifestyle experienced in the home satisfies their social, cultural and recreational interests. Service users maintain contact with their family and friends as they wish. Service users are helped to exercise choice and control over their lives Service users receive a wholesome diet in pleasing surroundings. EVIDENCE: Feedback from pre inspection questionnaires, observations made on the day of inspection and discussion with service users and their relatives demonstrated that no programme of social, physical or cultural stimulation is in operation within the home. Regular spiritual observance is, however, offered and appreciated by those that choose to attend. It is required that a full and diverse programme of activities is provided by the home. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 15 On the day of inspection a large number of friends and relatives were observed at the home. Those spoken to felt that they have a warm welcome and that their visits are valued by their relatives and friends. A “Friends of Hawthorns” group has been started with regular meetings held to arrange fundraising activities, social events and to address group needs and requirements from the service user group with the manager and proprietors of the home. The attendance of one of the proprietors of the home at a recent meeting was much appreciated. It is recommended that the proprietors continue to attend “Friends” meetings as regularly as possible to improve communication between all parties. Service users exercise some autonomy and choice in their lives. One service user handles their own financial affairs. Individual rooms were seen to contain a wide variety of personal possessions. The manager stated that service users or their relatives (with consent) could look at their records. An interested and hardworking cook is employed by the home. They are present for the entire day; so all meals are freshly cooked. On the day of inspection a gaily iced cake was prepared for a service user with a birthday. Food is of a fairly plain nature, but was observed to be well presented and in good quantities. Service user likes and dislikes are communicated to the cook, who is also responsible for going round the home and speaking to service users individually about their daily food choices from the menu. Service users requiring assistance were observed to be fed appropriately and respectfully. The inspector noted that Lunch is served very early at 12 noon. It is recommended that the home checks with service users in their next satisfaction survey that this timing is acceptable to them. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 16 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 The overall outcome for these standards is good. Formal complaints are dealt with appropriately by the home. It is less responsive to informal complaints. Service users are protected from abuse. EVIDENCE: The overall quality outcome for these standards is adequate. Evidence of appropriate investigation of formal complaints was seen in the home’s complaints file. Feedback from service users relatives and representatives demonstrated that informal complaints, comments and suggestions can sometimes take a long time to be acted upon by the proprietors of the home. Examples of this were the fact that a resident’s telephone had taken over two weeks to be attended to, and that the television reception in some individual rooms has been very poor. Investigation of the root cause of these problems identified that a lack of handy person and gardening resources is key. It is required that the proprietors of the home make sufficient resources regularly available in order that such comments and complaints are addressed. It is recommended that a record of all informal comments and complaints as well as compliments about the home are kept and audited to give feedback to the manager and proprietors about action and achievements. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 17 Training records demonstrated that most staff have now received adult protection training. Service users can store valuables safely. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 18 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, 22 and 26 The home is not always regularly maintained. Service users do not always have the specialist equipment they require to maximise their comfort and independence. The home is clean, pleasant and hygienic. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 19 EVIDENCE: The home is comfortable and homely There have been some improvements in decoration since the last inspection, but some areas, particularly kitchens, sluices and bathrooms are in need of redecoration. The environmental health officers’ most recent visit recommends refurbishment of the kitchen. The proprietor present on the day confirmed that this work is in progress, and that the home is currently exploring how food will continue to be prepared whilst this work is undertaken. It is required that the proprietors of the home continue to refurbish and refit the home, particularly the kitchen, to acceptable standards. The gardens were found to be tidy. Relatives present on the day stated that this is a recent improvement and that in the past they have done gardening themselves, as the home has no regular gardener. The inspector discovered two pieces of fire escape equipment to be out of order, and comments were made about other items not being repaired. The cause of speedily remedied repairs seems to be the fact that the handyperson post has been vacant for 6 months, with the home sharing the services of a worker with other homes on an “ad hoc” basis. It is required that the proprietors provide planned maintenance hours available to the home on a regular basis. Relatives of service users commented positively about the hard work and attention to detail paid by the visiting handyman to matters when he is able to deal with them. The home has a range of equipment to help people to maximise their independence. Unfortunately bathrooms were found to be cluttered with wheelchair equipment, which makes an unsafe and institutional environment. It is required that all bathrooms are kept free of clutter to ensure a safe and non-institutional environment. During the inspection the inspector noted that a number of service users spend long periods of the day in wheelchairs rather than domestic seating. One service users’ legs were resting against footrests with a potential of pressure damage. Investigation of these issues revealed that the home should take advice from Occupational Therapists about providing appropriate comfortable seating for people who have difficulties using the seating available in the home. It is required that professional guidance is taken to ensure that service users have appropriate, safe and comfortable seating at all times. The home is clean and hygienic, and staff work hard to ensure a fresh environment is maintained. Infection control systems are in place. Storage bins for waste are used appropriately. Sluices are available and in working order. Staff are required to wear protective clothing when entering the kitchen. A contract is held with an external company for regular pest control. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 20 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 overall quality outcome for these standards is adequate. The numbers and skill mix of staff may not always meet service users’ needs. The home has not achieved its NVQ training targets. Service users are not always protected by the homes recruitment procedures. Shortfalls in staff training have been identified. EVIDENCE: Some feedback from service user and relative feedback forms indicates that staffing levels may not be adequate. Observation made by the inspector on the day demonstrated that sufficient care and ancillary staff were on duty. It is clear that on some occasions shortfall in staff caused by unplanned absence means that the homes’ acting manager has to undertake care and domestic tasks. This is clearly an inefficient use of management time. Examination of some administrative records showed that the acting manager would also benefit from consistent administrative support. It is required that adequate staffing and administrative resources are in place to support the management of the home. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 21 The home has yet to achieve targets required by the commission for NVQ training. It is required that a programme of NVQ training is pursued by the home to enable targets set by the commission to be achieved. Examination of staff files demonstrated that CRB checks are not always in place prior to staff commencing work in the home. In addition one file was found to have no references, and a contract with another company owned by the proprietors. The proprietor confirmed that references had been gained on this person but are held elsewhere. Interview notes were not found on files. Original identification had been copied but not certified as such by the acting manager. Evidence of file checking was seen. It is required that a documented recruitment process that meets the requirements of the standards is written and implemented. CRB checks must be in place prior to staff commencing work. Evidence of staff induction was seen on files. A training record is held for each worker, and an analysis of training shortfall has been undertaken. The acting manager is in the process of organising a training plan for the home. It is recommended that the training plan for the home is completed and implemented. Observations by the inspector on the day of inspection indicate that dementia care training for staff may be beneficial. It is recommended that dementia care training is made available for staff. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 22 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, 33, 35, 36 and 38 The overall quality outcome for these standards is good. The home does not have a permanently appointed manager. The home is run in the best interests of service users. Service users financial interests are safeguarded. A system of supervision has been commenced. The health safety and welfare of service users and staff are promoted and protected. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 23 EVIDENCE: An acting manager who has been in place for just over one year is currently running the home. It is required that this post is filled permanently. A further service user satisfaction survey has been recently conducted, and a report on its outcomes is planned. Evidence of some auditing of events and information was seen. It is recommended that auditing of the home is continued and expanded. Individual personal funds are held for most service users. Meticulous records are kept, and monies checked were found to be accurate. Since the last inspection the acting manager has commenced a system of appraisal and supervision. Appraisals have been completed for all staff, and supervision commenced for some. Demands on the acting managers time have hampered this process and need addressing. (See previous requirement standard 27) Evidence of training in statutory health and safety matters was seen in staff files. Evidence was also seen of regular maintenance checks. Window restrictors and radiator guards are in place. Evidence was seen that risk assessments are undertaken and accidents are recorded and reported appropriately. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 24 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 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 2 9 2 10 2 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X 2 X X X 3 STAFFING Standard No Score 27 2 28 1 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 3 Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 25 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 OP19 Regulation 23 Requirement The registered providers must continue to complete the re decoration and upgrade areas throughout showing signs of wear and tear. Third Repeated requirement The registered providers must ensure there is an ongoing training programme, including NVQ Training, in place to promote the professional development of all the staff Second Repeated Requirement The registered providers must ensure that those responsible for supervising staff should undertake appropriate training. Second Repeated Requirement The registered providers must review the food preparation areas to ensure they are safe and well maintained to a good standard and in line with the requirements and DS0000044394.V300507.R01.S.doc Timescale for action 30/11/06 2 OP30 18i 31/08/06 3 OP36 18 30/11/06 4 OP38 23 31/12/06 Hawthorns Nursing Home Version 5.2 Page 26 recommendations made by EHO Third Repeated requirement. 5 6 7 8 OP8 OP9 OP9 OP10 Schedule 3 13 13 12 Causes of skin tears and other minor injuries are to be investigated, noted and audited Name of service user and date of opening to be noted on all opened liquid feeds. Medication records must be regularly audited to identify shortfalls in recording. The manager must ensure that good professional relationships exist between staff and service users. A programme of stimulating social, physical and cultural activities must be made available in the home. The proprietors must ensure that there are sufficient resources to respond to comments and complaints made by service users and their relatives. The proprietors must ensure that sufficient planned maintenance hours are available to the home on a regular basis. Service users must be provided with safe, suitable seating within the home. The proprietors must ensure that adequate administrative resources are available to the manager on a planned and regular basis. A documented recruitment process must be written and implemented, with CRB checks in place for staff in place prior to commencing work. Unless they are under constant supervision in line with Department of Health POVA1 guidelines. The proprietors must appoint a permanent manager who is DS0000044394.V300507.R01.S.doc 31/07/06 31/07/06 31/07/06 31/07/06 9 OP12 16 31/08/06 10 OP16 23,18 31/07/06 11 OP19 18 31/07/06 12 13 OP22 OP27 16,23 18 31/08/06 31/07/06 14 OP29 19 31/08/06 15 OP31 8, 9 30/09/06 Hawthorns Nursing Home Version 5.2 Page 27 registered with the commission upon appointment. 16 OP22 23 Wheelchairs and other equipment must not be stored in bathroom areas 31/07/06 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 2 3 4 5 8 9 Refer to Standard OP7 OP8 OP7 OP15 OP33 OP12 OP30 Good Practice Recommendations Staff must ensure that written records are legible. Service users should be regularly encouraged to take liquid refreshment. A social history should be taken, with the service users permission, to help staff see service users as a “whole” person. Service users should be asked if the existing times of meals are suitable for them. The auditing process that exists in the home should be continued and expanded. Care staff should inform the nurse on duty on all occasions of the reasons why they are returning a service user to their room before doing so. It is recommended that dementia care training be offered to care staff. Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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 Hawthorns Nursing Home DS0000044394.V300507.R01.S.doc Version 5.2 Page 29 - 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!