CARE HOMES FOR OLDER PEOPLE
Hawthorns Nursing Home 270 Unthank Road Norwich Norfolk NR2 2AJ Lead Inspector
Mrs Susan Golphin Unannounced Inspection 15th May 2007 09:00 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 Hawthorns Nursing Home DS0000044394.V341812.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.V341812.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 01603 507523 thehawthorns@schealthcare.co.uk Southern Cross Healthcare 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.V341812.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 14th June 2006 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 and/or care needs. The accommodation is on two floors and consists of 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 £446 to £551 per week. Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Care services are judged against outcome groups which assess how well a provider delivers the service to people. The key inspection has been carried out by using information from previous inspections, information from the manager, the residents and their relatives, as well as others who work in or visit the home. This report gives a brief overview of the service and the current judgments for each outcome group. At the last key inspection carried out in June 2006 sixteen requirements and seven recommendations were made. A random visit was carried out in October 2006 to monitor compliance and improvements to the service. Not all the requirements and recommendations had been met. In December 2006 the ownership of the home changed from Alpha Care Services UK (Ltd) to Southern Cross Healthcare. What the service does well: What has improved since the last inspection?
Several of the requirements and recommendations made at the previous inspection and relating to the upgrade and refurbishment of the premises are being addressed. Maintenance hours have been increased to help ensure the planned programme continues. Requirements relating to the standards of residents’ personal and nursing care and record keeping are also under review with the introduction of new care planning process and records. A second environmental health inspection was carried out in February 2007 as a follow up to the first inspection in December 2006 where the home scored ‘no stars’ rating. The management have complied with the report and have now achieved a three star rating. Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 6 The manager has instigated regular meetings with relatives and with the staff so that issues or problems can be discussed and dealt with openly and efficiently. New mobility equipment and specialist care beds have been purchased and are in use. Fluorescent light fittings have been replaced with more homely style lighting. The kitchen area has been refurbished, although the extractor fan has yet to be installed. Replacement carpets for the corridors, reception area and some residents’ rooms will be replaced within the next two months. The new manager was appointed at the beginning of March 2007 and is working through the improvement plan for the home and promoting better professional relationships with relatives and staff. Staff and relatives and residents were very complimentary about the manager saying that she is very accessible and has an open style of management which they feel is helping to stabilise the service and maintain improvements. Since the last inspection there is evidence of improved standards of care and overall management of the service including the supervision of staff and monitoring of practice. What they could do better:
The providers need to ensure that the manager is able to give all her dedicated working hours to this service. Currently the manager is being asked to assist in the management of another home and relatives have expressed their disquiet about this arrangement saying that in the manager’s absence small improvements in good practice achieved since her appointment are not being adhered to. One relative has said that despite a good start they are losing confidence in the providers to improve and sustain the overall standards of the home. In recent months there have been a number of staff changes affecting the stability of the service. New staff have been appointed and basic and mandatory training is taking place through the provider’s own training processes, and the induction process. Direct and indirect supervision of all the staff needs to be monitored to ensure consistency of standards. NVQ training also needs to be promoted and opportunities for staff to complete formal training encouraged. The quality of the service at mealtimes continues to be reviewed to ensure that relatives’ and residents’ concerns about the way people are assisted to eat and the way in which food is prepared and served are addressed. Some improvements in approach and practice have been made, but from the comments from relatives the improvements are not always being maintained when the manager and senior staff are not on duty. The manager has a good range of skills and experiences to bring to this post and wants to concentrate on developing a clear managerial structure within the home that the staff and residents and relatives can depend on. The manager
Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 7 and the senior team want to focus on consolidating the improvements and changes already in place as well as promoting future developments to improve the service. An application to register the manager with CSCI should be submitted as soon as possible, this will help to promote confidence in the management of the home and to improving the stability and consistency and standards of care. 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. Hawthorns Nursing Home DS0000044394.V341812.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.V341812.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. JUDGEMENT – we looked at outcomes for the following standard(s): Key Inspection Standards 3,6 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. Information about the service is available to prospective residents and their families so that they can make informed choices about their choice of home. Residents are only admitted to the home on the basis of a full needs assessment being completed. EVIDENCE: There have been some improvements to the way in which information is shared with both relatives and residents. The reception area has been cleared of the two notice boards which tended to be cluttered with paper and various notices. The Statement of Purpose and the Service User Guide along with the last inspection report is located by the reception desk. The four residents spoken to on the day have all lived in the home for some time and could not recall what they were told about the home prior to their admission. One resident said that when he visited the home he was told enough about it to
Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 10 want to live at The Hawthorns. Others said that when they and their family visited the home prior to living in the home they thought the staff friendly and the atmosphere pleasant. Four residents files were also seen giving details of completed needs assessment and reviews. The assessments are signed and review dates entered. There is no discrete intermediate care provision in this home, although prospective residents can be offered respite care as part of the overall admission process. Hawthorns Nursing Home DS0000044394.V341812.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. JUDGEMENT – we looked at outcomes for the following standard(s): Key inspection Standards 7,8,9,10 People who use the service experience adequate quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. There is evidence to support noticeable improvements in the care planning processes and in the way in which residents’ personal and health care needs are being met. Further improvement in the quality and the consistency of personal care should maintain good standards. The policies and procedures in place for the management of medication promote good practice. EVIDENCE: Individual care plans for each of the residents are in place and are established from the initial assessment of need. The manager has recently revised the care planning and risk assessment documentation with one of the senior nursing staff and a new format has been introduced. The information is clear
Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 12 and up to date, though this review has yet to be completed. The daily reports and records are the responsibility of the nursing staff who monitor the day to day care of the residents. The daily reports are brief and confirm the care plan in practical terms and reflect the physical and medical aspects of resident’s health care. There is less detail around the general mood or sense of well being of residents and this is one area that the manager is monitoring for clarity and legibility of information. see recommendation. New stand aid equipment and hoists have been purchased and a further two specialist beds and ‘profile’ mattresses have also been ordered. Wound care and pressure area management is monitored by the nursing staff and the manager carries out a monthly audit, and it was noted that since the last inspection the staff are more careful about monitoring residents’ skin tones especially those who are less mobile than others and as a result there have been fewer notable skin incidents, (pressure), marks and skin tears reported. Three of the medication records and the corresponding medication were looked at during the inspection and were found to be in good order. The three medication administration records were also up to date and well maintained. The manager confirmed and provided an up to date record of the medication audit that is carried out each month. There is a cross check process in place and each audit is usually carried out by one of the company managers external to the home. Four residents and two relatives were spoken to on the day of the inspection and all commented on the improvements made by the new providers in the previous few months and added that the staff are ‘very good’ and that they were happy with the way they are cared for. Other staff were observed supporting residents in their daily care in a competent and kindly way. One of the senior staff also commented on the overall improvements in the way the home is being managed and that the standard of service to the residents was ‘getting better’. One resident said that staff are respectful and considerate, but that ‘it would be nice if they could spare a few minutes each day just to chat and ask about how people feel and give them time to reply ’ see recommendation Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 13 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): Key inspection Standards 12,13,14,15 People who use the service experience adequate quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. There is evidence of improvements in the group social activities available. Individual recreational and social interests should also be improved. There is evidence of improved standards in meals and service, but further supervision is needed to maintain the improvements. EVIDENCE: From the discussions with the four residents and two staff and the manager it was said that there is some form of group activity offered each afternoon. One resident said that they like the music sessions and could recall one recently. Another said that they had enjoyed one of the quizzes. The manager confirmed that there are regular events held in the home including a garden fete in August. One resident said that they are not ‘a great fan’ of group activity and would appreciate a little individual /social time with the staff just for a chat and the opportunity to discuss how they feel. Encouragement is given to residents to act independently and one resident regularly goes out shopping and socialising
Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 14 and is currently planning her birthday lunch to be held at a local hotel. See recommendation A small dining area has been created in the main sitting room and offers an alternative place to eat for those who do not wish to take their meals in their rooms all the time. There is a planned menu and the catering staff consult residents about the daily choices and options available. One resident said that the meals in general and meal choices has improved recently and that lunch is now served later than 12 midday which was thought to be too early. The manager stated that staff can access snacks and light meals for residents throughout the 24 hours as required. One resident said that the meals are fine and there is plenty of choice if ‘what’s on the menu doesn’t suit’. Another resident said that they like the meals, but could not remember what they had ordered for lunch that day. Relatives have raised issues about the way meals are served and have suggested ways in which the mealtimes can be a more pleasurable and relaxed occasion, suggesting that the sweet is not served whilst residents are still eating their main courses. The manager has been happy to acknowledge this idea and bring it into use. From the comment card returned to the CSCI one said that the meals lack imagination with ‘overcooked vegetables and no salads’ see recommendation Residents requiring assistance were observed being helped to eat by staff appropriately. In the discussions with the senior staff it was agreed that all new staff should receive good practice guidelines on how to help people to eat as part of their overall induction to care. Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 15 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): Key inspection Standards 16,18 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. Arrangements for dealing with and responding to complaints have been improved. Some staff have received training on adult protection issues and understand how to report poor practice which helps protect residents. EVIDENCE: There have been no formal complaints to the CSCI about this service. Howeve, the CSCI are aware of individual concerns raised by relatives directly with the management. The home has a well established ‘relatives support group’ and ‘Friends of Hawthorns’ committee who are regular visitors to the home and have some daily input to their relatives’ care. Any issues relating to care practice or service delivery are shared with the manager or senior staff immediately. Relatives and residents said that there have been noticeable improvements in the overall service, but the changes for the better are not always maintained when key/ senior staff are not on duty. The new manager is holding regular meetings with relatives and staff to resolve any outstanding areas of concern and to promote better working relationships and continued improved services for residents.
Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 16 Training for staff in the protection of vulnerable adults and abuse awareness is provided through the company’s own trainers as part of the induction programme. The last training session was in March 2006 and refresher training is planned for 14th July 2007 when three sessions are scheduled to take place throughout the day. The senior and longer serving staff were able to demonstrate that they are able to recognise poor practice and also how to respond to allegations of abuse. Criminal Records Bureau disclosure checks for all the staff are on file. Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 17 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): Key inspection Standards 19,20,25,26 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. Significant improvements to the premises and external areas have been made and provide comfortable and pleasant living areas for residents. EVIDENCE: Since December 2006 when there was a change of ownership there have been a number of improvements to the premises. The external grounds and gardens have been cleared and tidied and additional wooden storage facility located to the rear of the premises. Internally there is a maintenance and redecoration programme in place that includes replacement of light fittings, carpets in reception, sitting room, and corridors. Furniture and additional specialist beds and mattresses are also on order. The reception area has been re-organised and is both neater and more
Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 18 homely looking. Residents and relatives both commented on the improvements especially the attractive and tasteful new pictures. The kitchen area has been upgraded in part. The extractor fan has still to be installed, but this work cannot be completed until planning permission has been received and there is some unknown delay in this being granted. The requirements made by the Environmental Health Officer at the original visit in November 2006 have been met and as an outcome of a follow up visit the home has achieved a three star rating. A brief tour of the ground floor areas was undertaken and included three residents rooms, the sitting/dining room, reception, kitchen and the conservatory. Improvements to the conservatory are planned for later this year and will include the installation of air conditioning and redecoration. Improvements to the bathroom facilities have also been made and the more orderly storage of wheelchairs and other equipment is in place. On the day of the inspection the home was clean and well maintained to a good standard. See recommendation Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 19 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): Key inspection Standards 27,28,29,30 People who use the service experience good quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. Recruitment and selection processes in place help to safeguard residents and staff. There are sufficient numbers of staff to meet the current care needs of residents. Improvements in the quality of the service delivery should be maintained through the reinforcement of good practice and relevant training. EVIDENCE: From the details in the duty rotas submitted to CSCI and from the discussions with the manager and the staff there are adequate numbers of staff on duty throughout the waking day and night, with one qualified nurse on duty at all times throughout the 24 hours and up to five care assistants. The care staff are also supported by separate domestic and catering staff. Residents said that the staff are helpful and usually responded promptly when they call for assistance. One resident commented that on occasion there might be a delay if the staff are busy, especially in the mornings and evenings. Another said that it can be busy at weekends or if members of staff are off sick, but that lately this had improved and there seemed to be ‘more people about’. One of the senior and longstanding members of staff said that overall the staffing levels have improved and the staff team arrangements have been
Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 20 revised. The changes in the way they work has helped everyone to focus more on their own role and in doing so provide care in a more dignified and unhurried way. From two of the staff files seen, there was evidence to show that the recruitment and selection processes had been followed including obtaining references and checking on identity, criminal records disclosure and previous employment. Two recently appointed staff were seen on the day of the inspection and both said that they had received training and support from senior staff during the induction period, and that they felt confident about their practice, but acknowledge that their experience is limited, thoughthey can rely on the senior staff and the nurses for support and advice. The staff group have a good range of skills and experiences and seven of the fourteen care staff have achieved an NVQ qualification. Staff training records provided some evidence of relevant training and the manager confirmed that there will be a continuing commitment to mandatory and specialist training this year including dementia training. See recommendation During the discussions with one relative they said that the staff social skills differ. Most of the time staff can respond appropriately to residents needs. However, some of the less experience staff still have some institutional approaches and would benefit from gaining insight and a greater sensitivity into residents’ cultures and beliefs and previous lifestyle so that they can develop a better understanding of resident’s own expectations and care needs and respond accordingly. See recommendation Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 21 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): Key inspection Standards 31, 32, 33, 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using a range of evidence, including a visit to the service. A suitable and appropriate manager has been appointed to the home. The management of the home has improved and the interests and health and safety of the residents promoted and protected. EVIDENCE: The new manager of The Hawthorns Mrs Sibongile Malevu, is a qualified nurse with a wide range of experiences and practice in the care of older people and has been in post since March 2007. The manager has yet to submit an application to be registered with the CSCI. See requirement.
Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 22 The manager now has administrative support of 5.25hrs, Monday to Friday. During the discussions with staff and residents and relatives all expressed very positive feedback on the significant improvements made to the service by Mrs Malevu which include regular meetings with staff and relatives and residents to discuss issues and to share information becoming established. Both staff and relatives said that they felt confident and reassured by the commitment and strength of leadership demonstrated by the manager and the good effect on the standards and service. However as previously stated at the time of this inspection the Manager is being asked to help in the management of another of the company’s homes and the staff and relatives have both expressed concern at this decision. The manager and senior staff are at an early stage in the improvement and promotion of this home and need time to consolidate the significant changes and ensure continued stability of the service. There was evidence in place to show that staff receive Health and Safety training and that regular maintenance checks are carried out throughout the home and recorded. A record of all accidents and incidents is maintained and audited by the manager each month. The Quality Assurance process for the service needs to be reviewed and refreshed for this year. The views of the residents and their representatives; staff and other health care professionals should be sought and the outcomes published and made available to all involved. See requirement Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 23 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 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 2 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 x 18 3 3 3 x x x x 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 2 x x x x 3 Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 24 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 Requirement 9 It is required that the manager submit an application to be registered to the Commission for Social Care Inspection. 24 It is required that the quality assurance processes for the service are reviewed and revised and the views of the residents, relatives and staff sought as part of this process. The findings of the quality assurance process should be made available to service users and their relatives. 30/06/07 2 OP33 30/09/07 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 OP7 Good Practice Recommendations It is recommended that the revision and introduction of the updated format for care planning is completed and that the manager reviews the style of reporting and recording to ensure there is a holistic view of residents care.
DS0000044394.V341812.R01.S.doc Version 5.2 Page 25 Hawthorns Nursing Home 2 OP10 3 OP12 4 5 6 OP15 OP18 OP19 It is recommended that all new staff are supported and supervised to develop positive relationships with residents that promote and support individual lifestyles and avoids institutional practice and routines, and continue to improve the quality of care offered to residents It is recommended that resident’s are offered the opportunity to pursue individual social activities and pastimes in keeping with their chosen lifestyles and interests. It is recommended that the recent improvements made to the way in which meals are served and presented be maintained and monitored to ensure continuity of service. It is recommended that the protecting vulnerable adults training for all staff is completed on the due date as planned. It is recommended that the upgrade and refurbishment programme for the home is continued and completed as soon as possible, including the designated work on the kitchen areas. Hawthorns Nursing Home DS0000044394.V341812.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Norfolk Area Office 3rd Floor Cavell House St. Crispins Road Norwich NR3 1YF 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
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