Inspection on 11/03/08 for Hawthorns Residential Home

This inspection was carried out on 11th March 2008.

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 Residential Home 13/02/07

Hawthorns Residential Home 08/02/06

Similar services:

Turret Villa Retirement Home

Moor House

Mendip House

Beaconsfield Court Care Home

Little Sisters Of The Poor

Manor House

Middleton Hall Ltd

Middlesbrough Intermediate Care Centre

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

CARE HOMES FOR OLDER PEOPLE Hawthorns Residential Home High Street Loftus Saltburn-by-Sea TS13 4HW Lead Inspector ALAN BAXTER Unannounced Inspection 11th March 2008 10:15 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 Residential Home DS0000064898.V354175.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 Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorns Residential Home Address High Street Loftus Saltburn-by-Sea TS13 4HW 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) 01287 641508 P/F 01287 641508 Mr Justin Ignatius Lawrence Russi vacant Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2007 Brief Description of the Service: The Hawthorns is a detached, two storey stone built house, set back from the road with a pleasant front garden with trees, lawns and borders containing shrubs and flowers. The home is situated close to community facilities. Accommodation for the 15 service users is provided in 11 single bedrooms and two double bedrooms. There are no en-suite facilities in this home. The home has two lounge/dining areas, which overlook the garden. A stair lift is available for those service users requiring assistance to access first floor facilities. The resident’s fees currently range from £285.83 per week (shared bedroom) to £385.83 per week (single bedroom). Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that people using this service experience adequate quality outcomes. How the inspection was carried out Before the visit: We looked at: • • • • • Information we have received since the last visit on 13th February 2008. How the service dealt with any complaints & concerns since the last visit. Any changes to how the home is run. The provider’s view of how well they care for people. The views of people who use the service & their relatives, staff & other professionals, both in person and using questionnaires. The Visit: An unannounced visit by the inspector and by Mr Malcolm Haddick, ‘Expert by Experience’, was made on 11th March 2008. During the visit we: • • • • • • Talked with people who use the service, relatives, staff, the manager & visitors. Looked at information about the people who use the service & how well their needs are met, Looked at other records which must be kept, Checked that staff had the knowledge, skills & training to meet the needs of the people they care for, Looked around parts of the building to make sure it was clean, safe & comfortable, Checked what improvements had been made since the last visit. We told the manager and the provider what we found. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 6 What the service does well: What has improved since the last inspection? Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 7 The new manager, experienced and qualified, has been appointed. She has introduced new care plans that more clearly describe the ways in which each resident’s needs are to be met. Laundry facilities have been much improved. The home’s ‘rolling programme’ of repairs and renovation is now back on schedule, and all the ground floor and some bedrooms have been re-carpeted. A new assisted bath has been fitted. Access to the home and the outside facilities are now back to normal, having been hampered by building work in the past year. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hawthorns Residential Home DS0000064898.V354175.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 Residential Home DS0000064898.V354175.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): 1, 2 and 3. People who use the service experience good quality outcomes in this area. People thinking of coming to live in the home are given the information they need to make an informed choice. Each resident has a written contract with the home. All new residents have had their individual needs fully assessed, and they are only accepted if the manager is sure that all those needs can be met by the home. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 10 The home’s statement of purpose and the service users’ guide are detailed documents that cover the necessary areas of information, and reflect good values in the home. It includes the home’s complaints procedure and information about how to access information about advocacy for residents. It needs to be updated, however, to include the details of the newly appointed manager of the home. None of the five residents who returned surveys felt that they had been given enough information before moving into the home. However, as the surveys are anonymous, it is not clear that these opinions relate to the information about the home currently available to people thinking of coming into the home. All five residents who returned surveys said that they had received a contract from the home. The home makes sure that it receives full information about the needs of new residents before it accepts them. This is in the form of formal assessments of need from the referring authority, and, where appropriate, hospital discharge summaries, occupational therapists assessments, etc. The manager also does her own assessment of the person’s needs, to make sure that she feels the home can meet all the identified needs. Hawthorns Residential Home DS0000064898.V354175.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): 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. Although new care plans are being introduced, the existing plans are not sufficiently detailed to show that residents’ health, personal and social needs are being fully met. Residents’ health needs are properly assessed and are met by using the full range of health services. Residents are protected by the home’s policies and practices about the storage and administration of their medicines. Residents are treated with respect by staff at all times, and have their privacy and dignity upheld. We have made this judgement using available evidence including a visit to this service. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 12 EVIDENCE: It was a requirement of the last inspection report that the manager should ensure that all the residents care plans contain sufficient individual detail relevant to the resident, so that the needs of the resident can be fully met by the staff. This is in the process of being carried out. The new manager was able to demonstrate that new, more detailed and individualised care plans have started to be drawn up and put in place. However, the large majority of residents still have only rudimentary care plans at the time of this inspection. All five residents who returned surveys said that they always receive the care and support they need. Of the four relatives who returned surveys, three said that the home always meets the needs of their relative living in the home; one said “usually”. Eight of the nine staff members who returned surveys said that they are given up to date information about the needs of the people they care for; one said “usually”. Health care needs are assessed before admission, and informally assessed thereafter. Any problems are noted in the Daily Health records for each resident, and there was evidence of appropriate referral onto the relevant health professionals. The Hawthorns is situated next door to a doctor’s surgery. This enables the staff to get medical attention for the residents very easily. The resident’s daily records show evidence of visits from doctors and nurses. The records also show evidence that the staff know what to do in the event of a problem with a resident’s health, and that they take appropriate action if there are concerns. There is appropriate documentation in place to meet health needs including, for example, toileting charts, accident charts, and fluid balance charts. Nutritional screening is being introduced. All five residents who returned surveys said that they always receive the medical support they need. It was a recommendation of the last inspection report that the medication policy should be amended to remove the reference to ‘nurse’ in relation to administering medication, as Hawthorns is a residential care home and does not have any registered nurses. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 13 This is in the process of being carried out by the new manager, who will also be seeing the home’s pharmacist to get a copy of the latest national guidance on pharmacy issues. The Medication Administration Records (MAR) was studied. It was generally well maintained, with no noticeable gaps. Security is good, with the drugs trolley secured to the wall when not in use, and ‘controlled drugs’ kept in a separate locked compartment in the locked metal wall drugs cabinet. All care staff have received accredited medications training. All those residents engaged in conversation confirmed that they are always treated with great respect by the staff, and that their privacy is respected. Staff were seen to relate well with the residents, and to treat them with dignity. Visiting relatives also confirmed that the staff treat the residents well at all times. Hawthorns Residential Home DS0000064898.V354175.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using this service experience adequate quality in this outcome area. There is a lack of a clearly planned and organised daily programme of social activities in the home. Religious needs are met. There is good support from visiting families and friends, and visitors are made welcome by the staff. There are regular links with the local community, and with local schools and churches in particular. Residents are helped to exercise choice and control over their lives. Residents get a varied, nutritious and enjoyable diet, with a good degree of choice and acknowledgement of individual likes and dislikes. We have made this judgement using available evidence including a visit to this service. EVIDENCE: It was a requirement of the last inspection report that the manager must arrange for an activities programme and records to be developed relating to Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 15 in-house and outside activities and consult with residents regarding proposed activities (this is an outstanding requirement from last two inspections). This has not been carried out. Although there are monthly trips to interact with children at a local school, some other occasional trips out to local shops, cafes etc, and that staff run occasional bingo, dominoes and music sessions, there was little evidence of regular daily social stimulation. There is a list of possible activities displayed on the home’s notice board, but no actual planned or published programme of activities. Study of the individual ‘daily social activities sheets’ showed that nearly all entries referred to passive activities such as ‘watched t.v.’; ‘listened to music’; and ‘read magazine’. Residents said that they are asked to contribute towards the costs of some trips out; some did not wish to do this, thus limiting the number of trips out. Once a month, a musical duo comes to the home to play guitar and sing. All five residents who returned surveys said that there are activities for them to take part in at the home. All four relatives who returned surveys said that the home always helps them keep in touch with their relative living in the home; and that they are kept up to date with important issues affecting their relative. There are no unnecessary restrictions on visiting by families and friends. The manager reported that most residents get regular visits, and that every resident gets at least an occasional visitor, but also that residents “share” their visitors, and look after each other. Some visitors spoken with said that the staff always make them feel welcome when they visit the home. Community links include the monthly visits to a local primary school. Both Anglican and Catholic priests visit the home weekly, and give communion to those who wish it. The home also jointly organises a summer fete each year with a local church. Residents were given a choice of food at meal times and this was evidenced by the menu and by observing staff ask residents what they would like to eat. Residents who were tired were given the choice of having lunch at a table or on a small table by their chair. Although meal times were set there was flexibility if someone wanted to eat later. Residents said they could also have longer in bed on a morning should they wish to do so. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 16 Much good practice by staff was seen during this inspection. Examples included staff helping residents maintain independence i.e. walking to the toilet rather than using a wheelchair with staff ensuring they did not fall, at mealtime, and giving them time to do things on their own. Residents also have choice as to what they wear, when they get up and go to bed, whether to join in activities etc. All five residents who returned surveys said that staff listen to them and act on what they say. The residents are consulted about the home’s menus, which are also checked with a dietician. The menus offer a good deal of choice, including a cooked breakfast and a choice of two different main courses for lunch. The cook is very flexible and is happy to meet individual requests over and above the menu. She keeps a list of individual food likes and dislikes for each resident. Fresh fruit is prepared and taken round each resident every day. This is good practice. Special diets are catered for, and the cook is undergoing further nutritional training. Lunch was taken with the residents. There was a choice of beef or ham, Yorkshire pudding, mashed potatoes, carrots, Brussels sprouts, and gravy. Dessert was cheesecake or fruit and cream, all of which was delicious and enjoyed by residents. A cup of tea was also provided. The tables were nicely set with matching cloth and napkins. Everything went well considering staff had to carry meals on a tray from the kitchen to the dining area (a reasonable distance). All meals were covered until presented to a resident. Residents are weighed monthly, to pick up any significant changes. Four of the five residents who returned surveys said that they always like the meals in the home; one said “usually”. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using this service experience good quality in this outcome area. Residents are confident that any concern or complaint that they might raise will be taken seriously and properly investigated. Residents are protected from abuse by the home’s policies and procedures and the appropriate training of staff. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The home has an appropriate complaints policy that is pro-active and welcomes comments, compliments, suggestions and complaints. Particularly good practice was noted in the section dealing with serious complaints, which gives the contact details of the local abuse co-ordinator, allowing a complainant to go straight to that person, and not necessarily via the home’s management. Some potential confusion as to when the Commission should be contacted about a complaint was discussed and resolved with the manager. The home’s complaints policy is displayed in all bedrooms. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 18 No complaints have been received in the past year. Conversations with staff members showed that they were aware of the complaints policy and procedures and knew what to do if action was required. All five residents who returned surveys said that they know who to speak to if they are not happy, and all five said that they knew how to make a complaint. All four relatives who returned surveys said that they know how to make a complaint about the care provided by the home if they needed to. Three said that the home always responds appropriately to any concerns raised; one said “usually”. All nine staff who returned surveys said that they know what to do if there are concerns about the home. One commented, “I have been taught to listen to [residents] and try and sort it out. If I can’t, I speak with my manager”. Another said, “We have firm guidelines in place”. Training of staff in the area of protection of vulnerable adults is arranged by the home. The staff training files show evidence of ‘No Secrets’ training done by the staff. The new manager is an accredited trainer in the protection of vulnerable adults, and so will be able to deliver future staff training in this important area herself. Residents state that they feel safe and discussion with staff members confirmed that staff have a good understanding of the correct procedures to follow if they suspect one of the residents is at risk of abuse, or has been abused. There have been no allegations of abuse, and no member of staff has been subject to any suspension, dismissal or other disciplinary action. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26. People using this service experience adequate quality in this outcome area. The home provides residents with a safe and homely environment, including comfortable indoor communal facilities, but it lacks any facility for the private discussion of confidential issues. Residents have access to safe and comfortable indoor and outdoor facilities. Residents have safe and comfortable bedrooms. The home is clean, pleasant and hygienic. We have made this judgement using available evidence including a visit to this service. EVIDENCE: Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 20 At the time of the last inspection, it was noted that the normal ‘rolling programme’ of refurbishment and redecoration of the home had been suspended whilst the construction of a new, separate home adjacent to Hawthorns was being built. This home has now been completed, and the programme for maintaining Hawthorns at an acceptable level of décor and repair appears to be back on course. New carpets have been laid throughout the ground floor of the home, and in a number of bedrooms. One bathroom has been refitted with a pedestal bath, with integral hoist. Staff facilities were poor with the “office” stuck in what looked like a passageway. It was impossible to discuss anything without someone “squeezing past”, and there being no privacy. Similarly the reception area was very small and immediately outside a resident’s bedroom, making any discussion again impossible without the risk of being overheard. The inspectors were able to discuss issues in privacy, thanks to the courtesy of a resident who kindly allowed us to use her bedroom for the duration of the inspection. We were informed that plans were in hand to make an office available. This must be made a priority. External access to the building was limited at last inspection, due to construction work on the adjacent new residential home. This work has now been completed, and normal access to Hawthorns has been reinstated. It was a requirement of the last inspection report that the registered persons should ensure that they repair or replace the bedroom furniture that is worn. This is in the process of being carried out, as part of a rolling programme. Two residents were happy to show the inspector their rooms. The bedrooms were well decorated, clean, and had a nice warm feel. Bedroom furniture was of acceptable quality. Both residents said that they were very happy with their rooms. The laundry function has been transferred to the newly built ‘sister’ home, adjacent to Hawthorns. This arrangement seems to be working satisfactorily. There is a cleaning programme checklist in each bedroom. This is kept up to date. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 21 All five residents who returned surveys said that the home is always clean and fresh. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 22 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using this service experience good quality in this outcome area. There are enough care staff to meet the current needs of the residents. Residents are in safe hands, because all the care staff have the relevant qualifications. Residents are protected by the care and checks used when employing staff. Staff are well trained and are competent to do their jobs. We have made this judgement using available evidence including a visit to this service. EVIDENCE: The home’s staff rotas were studied. These showed that the current staffing levels are: 8am-5pm:1 senior carer and 1 carer. 5pm-10pm: 1 senior carer and 1 carer. 10pm-8am: 1 carer awake and 1 carer asleep (but on call). Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 23 The manager is registered manager of both the Hawthorns and the adjoining home. She is available to the Hawthorns approximately 50 of her time, usually in the afternoons. The manager has discretion to increase staff hours, to meet any increase in resident needs; she may also access ‘bank staff’, at her discretion. This is good practice. Of the five residents who returned surveys, two said that staff are always available when they need them; two said that staff are usually available; and one said they are sometimes available. One commented that more staff are needed on shifts. Three of the four relatives who returned surveys said that the staff have the right skills and experience to look after people properly. One commented that not all staff have knowledge of Diabetes. Of the nine staff who returned surveys, three said that there are always enough staff to meet the individual needs of the residents; four said “usually”. One commented, “We always have plenty of staff.” Another said, “I think … more staff would help.” All fourteen carers hold National Vocational Qualification (NVQ) level 2 in care. This far exceeds the required minimum of 50 of care staff with this qualification. In addition, three care staff also hold NVQ level 3 in care, and another three staff are currently working towards this qualification. This reflects very well on all involved in the home. The manager is an accredited NVQ assessor. The staff are recruited appropriately and receive an induction training that covers all the necessary knowledge and skills to undertake their role. All nine staff who returned surveys said that the Proprietor carried out all the necessary checks, including Criminal Record Bureau (CRB) checks and written work references, before they started work. They also said that their induction covered everything they needed to know about the home. Study of staff training records showed that all staff are up to date with mandatory training, and refresher courses are booked in advance. Staff are involved in assessing and drawing up their own training needs. Training is also being identified to meet the needs the needs of individual residents (examples include training about Diabetes, palliative care and anger management). Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 24 All nine staff who returned surveys said that they are given training that is relevant to their role; helps them to understand and meet the individual needs of residents; and keeps them up to date with new ways of working. Five staff identified training as a particular strength of the home. All nine staff members also said that their induction training covered everything they needed to do their job. All nine also said that they are given training that is relevant to their role; helps them understand and meets the needs of the residents; and that keeps them up to date with new ways of working. Several commented that they are always getting new training and that courses are arranged whenever necessary. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 25 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36 and 38. People using this service experience adequate quality in this outcome area. The home’s manager is qualified and experienced to run the home. Hawthorns is run in the interests of the service user but quality surveys must be improved to ensure that the views of the residents inform all planning for the service. Resident’s financial interests are not fully safeguarded. Staff are appropriately supervised. The registered manager ensures so far as is reasonably practicable the health, safety and welfare of the residents and staff, but staff facilities are insufficient. We have made this judgement using available evidence including a visit to this service. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 26 EVIDENCE: The home’s manager, Mrs Judith Weedall, has the necessary qualifications and experience to carry out her role. She has been registered as manager of care homes elsewhere, and is currently going through the normal registration process on behalf of Hawthorns. An annual survey of residents’ views about the home takes place. However, the questionnaire is rather basic and could usefully be further developed. The manager conducts monthly quality audits of management issues, such as health and safety, staff sickness, risk assessments, training etc. The minutes of residents’ group meetings show an openness and awareness of residents’ wishes, and also show that issues raised by residents are responded to, promptly and appropriately. There were examples of changes being made to some of the home’s systems, to the menus, and the purchase of new items, in response to residents’ requests. Sampling of the financial records held for money held on behalf of residents showed some discrepancies (mostly small) between the account balances and the cash held for some residents. Some examples showed that there was less cash being held than the records required; others showed that more money was being held. Although there was evidence of occasional audit of the accounts, the system obviously needs an immediate overhaul, to make sure that the accounts are completely accurate at all times. Any shortfalls must be made good by the home. All nine staff members who returned surveys said that they meet regularly with their manager for support and to discuss how they are working. One commented, “She is always available”. Another said, “I can go to see her when I want”. Staff supervision records showed that staff are supervised at the required regularity (i.e. six times each year). The home’s manager currently carries out all these supervisions; but some delegation to senior staff is being considered. Annual appraisal takes place, and staff training and development needs are identified. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 27 It was a requirement of the last inspection report that the registered persons must ensure that the new laundry facilities and the facilities for staff are put into place as soon as is it possible to do so. This has been partly carried out. There are now suitable laundry facilities in place in the newly built care home, which is adjacent to Hawthorns and is managed by the same manager. However, plans for providing staff with suitable facilities for storage and changing have yet to be put into practice. This requirement is repeated in this report. The manager carries out monthly audits of health and safety issues, including fire safety, C.O.S.H.H., first aid, clinical waste, maintenance and accident analysis. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 28 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 2 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 2 3 X 2 Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 29 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 OP1 Regulation 6 Requirement The registered persons must ensure that the statement of purpose and service user guide are updated to reflect the recent change of registered manager. Timescale for action 30/04/08 2. OP7 15 The manager must ensure that 30/04/08 all the residents care plans contain sufficient individual detail relevant to the resident, so that the needs of the resident can be fully met by the staff. (This requirement is outstanding from 30/04/07). 3. OP12 16 The manager must arrange for an activities programme and records to be developed relating to in-house and outside activities and consult with residents regarding proposed activities. (This requirement is outstanding from the last two inspections.) 30/04/08 Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 30 4. OP19 23.2 The registered person must ensure that there are sufficient private office facilities to allow for the discussion of confidential issues. The registered person must ensure that a full audit of all money held on behalf of residents is undertaken, and any discrepancies between the account balance and the cash held must be made good by the home. Regular audits must take place thereafter. 31/07/08 5. OP35 17.2: Schedule 4.9 30/04/08 6. OP38 23.3 The registered person must ensure that staff have suitable facilities for changing and for storage. (This is outstanding from 30/09/07). 30/07/08 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 OP33 Good Practice Recommendations The homes annual quality questionnaires should be further developed, to provide better information and to involve residents and other stakeholders more fully. Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hawthorns Residential Home DS0000064898.V354175.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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