Inspection on 13/02/07 for Hawthorns Residential Home

This inspection was carried out on 13th February 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 11/03/08

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 Ania Swann Key Unannounced Inspection 13th February 2007 10:00 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 Residential Home DS0000064898.V330393.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.V330393.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 Mrs Karen Masding Care Home 15 Category(ies) of Old age, not falling within any other category registration, with number (15) of places Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 2006 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 are currently £340 per week. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the service lasting a total of eight and a half hours. As part of the inspection a range of records and documents were looked at including residents care plans and staff training files. Four completed service user surveys were returned to the inspector. The inspector had discussions with four residents and three relatives. A visiting professional who was in the home on the day of the inspection spoke to the inspector. Four staff including the manager of the home and the registered provider spoke to the inspector, and they were very welcoming and co-operative. A tour of the premises formed part of the inspection, and the inspector observed that there is building work underway at the rear of the home for a new service planned for by the registered provider of Hawthorns. What the service does well: What has improved since the last inspection? There is evidence to show that the staff have received ‘No Secrets’ training in adult protection and awareness of abuse. The percentage of care staff that have achieved NVQ Level 2 exceeds the National Minimum Standard. The carpet has been replaced in the hallway, corridors and stairs. Some of the bedrooms have also been re-carpeted. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 6 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.V330393.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 & 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents have the information they need to make a choice about where to live but the registered persons should ensure that this information is current and accurate. Residents receive a contract and have their needs assessed before moving into the home. Residents or their representatives have the opportunity to visit and assess the suitability and quality of the service. EVIDENCE: The statement of purpose does not contain current, accurate information about the number of staff employed in the home. The service user guide states that there is a shower on each floor, but there are no showers evident in the home. The registered persons should ensure that all information relating to the service is accurate and current so that residents and their families have clear and up to date information. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 9 Residents confirmed that they or their representatives had received a contract when they moved in, and that prior to moving in had the opportunity to visit the home and have a look around. The resident’s files looked at show evidence of a full assessment of needs undertaken by the local authority or the service prior to the resident moving in to Hawthorns. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents have a plan of care that sets out their needs, but this should be developed further to include more detail relevant to the individual resident. The health care needs of the residents are fully met. The home has a medication policy and procedures that should protect the resident. The residents feel that they are treated with respect. EVIDENCE: The resident’s files show that each resident has a care plan based upon an assessment of their needs. The care plans are variable; some contain a lot of detail that enables the staff to fully meet the needs of the individual. Other care plans looked at, contain basic information and should be developed to include particular details relevant to the individual resident. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 11 The Hawthorns is situated next door to a doctor’s surgery that 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. The home has a medication policy and procedures that the staff are aware of and understand. The policy refers to ‘nurse’, which is inappropriate as there are no registered nurses at the home. The wording of the policy should be amended. Records show that storage, administration of, recording and disposal of medicines is done appropriately and documented correctly. A resident told the inspector that “the staff treat you well – they always knock on the door before they come in”. The inspector observed staff with residents, and they were very patient with residents. Staff are noted to be very gentle and sensitive in their manner. There are double rooms in the home that have screens to maintain the individual residents dignity and privacy. The screens are very clinical, and do not suit a homely environment. The service could improve the screens to be more in keeping with the décor of the bedrooms. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents feel that the home could do more to meet their social, cultural, religious and recreational needs. The home does welcome and encourage the residents to maintain contact with family and friends. Some residents would like more independence than they have. The home provides the residents with food that is of good quality, well presented and meets the needs of the residents. EVIDENCE: Discussion with some of the residents highlighted that there is a need to develop the range of activities on offer for the residents. “We play bingo and dominoes and things like that – we don’t do something everyday – depends who’s on which staff do the activities”. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 13 “Occasionally I’d like to go out. I don’t get to go out much”. A relative commented “there could be more activities in the home for the residents to do”. The residents are able to have visitors at any reasonable time. Visitors that spoke to the inspector confirmed that the home does make them feel very welcome. “The family are always made very welcome when we come”. “The staff are very friendly”. A visiting professional told the inspector “it is one of the most friendly homes I go to. It’s a really nice place, really welcoming”. The inspector did observe during the inspection music being played and some of the residents singing along. Residents told the inspector that they enjoyed the food at the Hawthorns. “The food is good and there’s plenty of it”. The inspector joined the residents for a meal and observed that the food is freshly prepared, well presented and nutritious. There is a blackboard style menu board on display in the home. This is updated to show the meal for the day. The residents can choose an alternative meal if they do not like what is on offer. There was a good relationship evident between staff and residents during the meal. Staff helped those who needed assistance when eating, and they were sensitive in their approach. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have access to a robust, effective complaints procedure and are protected from abuse. EVIDENCE: Residents and their visitors told the inspector that they know how to make a complaint if they need to, but confirmed that they have not had any reason to do so. There is no evidence of any complaints or concerns received by the home in the past twelve months. The complaints policy was evident on the notice board in the hallway of the home. There is a clear complaints procedure that is easy to understand. Training of staff in the area of protection is arranged by the home. The staff training files show evidence of ‘No Secrets’ training done by the staff. Residents state that they feel safe and discussion with staff members confirmed that staff have a good understanding of the correct procedure to follow if they suspect one of the residents is at risk of abuse. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 15 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, 25 & 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Hawthorns provides its’ residents with a safe and homely environment. The home does provide safe and comfortable indoor communal facilities. The outdoor access to the rear of the building is restricted because of the extensive building work that is currently taking place. Residents have safe comfortable bedrooms with their own possessions around them. The home is generally clean and tidy, but the Hawthorns is experiencing some upheaval as a result of the building work that is taking place to the rear of the building. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 16 EVIDENCE: The service provides a homely environment. It has a rolling programme to improve decoration, fixtures and fittings, but this is on hold at the present time because of the building work that is taking place at the rear of the home to provide a new service in addition to Hawthorn. The carpet in the hallway, corridors and stairs has been replaced since the last inspection. Some of the bedroom furniture is worn and should be refurbished or replaced to improve the surroundings for the residents in their own bedrooms. There is a pleasant front garden where residents confirm they like to sit out when the weather is fine. At the present time, there is no access to the rear of the home because of the building work. The inspector saw evidence of residents own possessions in their rooms. The registered provider reports that the bedrooms have been painted since the last inspection. Residents can personalise their rooms and they choose where they want to sit in the lounge areas. The current laundry facilities are temporarily located in a room that is inadequate. The staff are restricted by the size of the room; there is very little space to operate the equipment and sort out the residents laundry. The inspector acknowledges that this is a temporary arrangement while building work is completed, but the registered persons must ensure that as soon as it is possible to relocate the laundry facilities, it is moved from its current position. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff in the home are trained and skilled to meet the needs of the residents. The service has a recruitment policy that is put into practice, and the residents are in safe hands. EVIDENCE: The staff duty rota shows that home has an adequate number of staff to meet the needs of the residents. Discussions with care staff confirm that they feel the current number of staff is sufficient; “I do think there are enough staff to look after the residents – I never feel I’m left out on a limb”. Residents and their family members told the inspector that they feel that the people living in the home are “really well looked after and well cared for”. One resident said “the staff never just leave you to sit in the corner and be ignored. They really take care of us”. The inspector looked at three sets of staff recruitment and training files. The staff are recruited appropriately and receive an induction training that covers all the necessary knowledge and skills to undertake their role. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 18 The staff receives relevant training including ‘No Secrets’ Protection Awareness and Dementia Care. Discussion with care staff confirmed that they find the training useful, and that they understand their role and responsibilities. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 19 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 & 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The registered manager is qualified and experienced to run the home. Hawthorns is run in the interests of the service user but the manager should ensure that the views of the residents informs all planning for the service. Resident’s financial interests are 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. She should ensure that the staff are assured of appropriate facilities, and that this should happen as soon as it is possible to do so. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 20 EVIDENCE: The manager has the necessary experience to run the home. One staff member told the inspector that “she is a good manager – she’s worked her way up and understands what we are doing”. The staff have a good working relationship with the manager and feel supported by her; “she’s fair and you couldn’t wish for a better boss”. There are quality assurance and quality monitoring systems in place such as questionnaires to residents and their families, and residents meetings. The manager should ensure that these views are used in the planning of the service and for making improvements such as an activity programme for residents. The registered persons confirm that the majority of residents handle their own money, and that they receive their full personal allowance to dispose of as they wish. Records are kept of the management of personal allowances, and there are facilities to keep any money safe. The inspector looked at evidence of up to date maintenance records for the home. Regular audits take place by the manager of the environment and a plan of areas that need to be addressed is evident. One area that needs addressing is the lack of facilities for staff and the current laundry facilities. During discussions with members of staff, the one area for improvement that they highlighted was the lack of basic facilities. The inspector does acknowledge that there are plans to have a staff room/meeting/training room for staff, and a purpose built laundry room in the building currently under construction at the rear of Hawthorns. The registered persons must ensure that this does happen. Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 21 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 2 X 3 X 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 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 X X X 3 2 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 3 X 2 Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 22 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 contain current and accurate information about the number of staff, and the facilities in the home. 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 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. Outstanding requirement from previous inspection The registered persons should ensure that they repair or replace the bedroom furniture that is worn. 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. Timescale for action 30/04/07 2. OP7 15 30/04/07 3. OP12 16 30/06/07 3. OP24 16 30/09/07 4. OP38 16, 23 30/09/07 Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 23 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 OP9 Good Practice Recommendations The medication policy should be amended to remove the reference to ‘nurse’ in relation to administering medication. Hawthorns is a residential care home and does not have any registered nurses. The screens in the double bedrooms should be more homely in appearance. The current screens are very clinical and more suited to a hospital clinic rather than a residents bedroom. 2. OP24 Hawthorns Residential Home DS0000064898.V330393.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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.V330393.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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