Inspection on 11/05/05 for Hawthorns, The

This inspection was carried out on 11th May 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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, The 23/05/07

Hawthorns, The 26/06/06

Hawthorns, The 19/10/05

Hawthorns, The 17/11/04

Hawthorns, The 10/05/04

Hawthorns, The 12/02/04

Similar services:

Polesworth Group Friary Road

Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

Polesworth Group 64 Long Street

Polesworth Group 68 Long Street

10 Whitfield Avenue

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

CARE HOME ADULTS 18-65 THE HAWTHORNS Walkmill Drive Wychbold Worcester WR9 7PB Lead Inspector Nic Andrews Draft - Unannounced 11 and 13 May 2005 9:00 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 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 Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service The Hawthorns Address Walkmill Drive Wychbold Worcestershire WR9 7PB o1527 861755 01527 861755 None Yunicorn Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) None CRH 3 Learning Disability 3 Category(ies) of LD registration, with number of places THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: In addition to the conditions of registration referred to on page 4 of this report, the home may also accommodate people with an associated physical disability or mental disorder. Date of last inspection 17 and 19 November 2004 Brief Description of the Service: The Hawthorns is a detached, residential property situated in a semi-rural area in a private drive off the main Worcester road in the community of Wychbold. The property is of modern design and appearance and has an enclosed rear garden. The premises has been operating as a residential care home since August 1995. The home is registered to provide accommodation and personal care for a maximum of three adults with learning disabilities who may also have a mental disorder or a physical disability. The service users are accommodated on the ground and first floor of the building. Each of the service users has their own bedroom. One service user has an en suite bathroom. The other two service users also have exclusive use of their own bathrooms. The home does not have a passenger lift or a stair lift. The communal space includes a combined lounge and dining area, a snoozelun and a conservatory. The service users have needs that fall within the Autistic Spectrum Disorder range of disability and have behaviour which challenges. The main purpose of the home is to offer long term care and to provide a high quality, needs led service that enables the service users to maintain community networks and to develop new opportunities. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two days. The majority of this time was spent with the acting manager and registered provider. The home’s response to the 32 requirements and 22 recommendations that were made as a result of previous inspections of the home was assessed. A tour of the premises took place and the records that were maintained in respect of both the staff and service users were inspected. What the service does well: What has improved since the last inspection? 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 HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2 ,4 and 5, Documentation was in place, some in pictorial format suitable for service users. The home’s statement of purpose, service users’ guide, assessment form and contract were inadequate and did not provide sufficient or accurate information to enable prospective service users or their representatives to be clear about the services the home provided to meet their needs. EVIDENCE: The home had a statement of purpose. The requirement that had been made as a result of previous inspections to improve the contents of the statement of purpose had still not been fully implemented. The statement of purpose did not include: • The relevant qualifications and experience of the registered provider, • The full details of the organisational structure of the care home, • The age range of the service users for whom it is intended that accommodation should be provided, • The range of needs that the care home is intended to meet, • The size of all the rooms in the care home. In addition, the statement of purpose stated, ‘The person officially registered to manage the home is Mrs Lynnette Land’. Mrs Land has not been registered to manage the home and her application to be the registered manager has been refused. The statement is, therefore, misleading and must be deleted. It was pleasing to note that the home had a service users’ guide that had been produced in both a pictorial and written form. However, it was noted with THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 8 concern that the requirement that was made as a result of the previous inspection to amend and improve the contents of the written form of the service users’ guide had not been implemented. The service users’ guide did not include: • Key contract terms covering admission, occupancy and termination of contract, • Fees charged, what they cover, and the cost of ‘extras’, • Service users’ views of the home (user surveys), • A copy of the home’s complaints procedure, • A statement to the effect that a copy of the most recent inspection report on the home is available to service users and their families. In addition, the service users’ guide stated that the home aims to provide care ‘for up to 4 people’ when the home was only able to accommodate three people. The service users’ guide also referred to ‘the one vacancy at the home’ when, in fact, the home did not have any vacancies. These statements were misleading as the home was only registered for a maximum of three people. These statements must be deleted. The service users’ guide also contained out of date references to the former deputy manager and to the former National Care Standards Commission. The three service users had undergone a Community Care Assessment prior to their admission to the home. The home also had an assessment form that was used by the staff to assess the care needs of the service users. A copy of one of the completed assessment forms was made available for inspection. The assessment form was inadequate for its purpose. The form did not include several of the issues listed in Standard 2.3. For example, there was no reference in the assessment form to meaningful education, training and/or occupation, adequate income, mental health care, treatment/rehabilitation programme and compatibility with others living in the home. In addition, there was limited information in the assessment form regarding the provision of disability equipment and specific condition-related needs and specialist input. The form did not include the name and address of the home and did not state the name of the person responsible for carrying out the assessment. The amount of space allowed within the form for recording the relevant information was also insufficient. The home’s assessment form must be reviewed and amended in order to address all of these deficiencies. The current service users had been resident at the home for several years. No new service users had been admitted to the home for approximately eight years. The acting manager stated that she supported the practice outlined in Standard 4 regarding pre-admission visits by prospective service users. The service users’ guide that was in written form referred to a one-month period in which the service users could decide whether The Hawthorns ‘is the home for them’. The service users’ guide that had been produced in pictorial form stated ‘The first three months are for you to settle in’. However, it also stated ‘When you move in everyone has one month to decide if everything is OK’. The trial period should be three months. Neither of the two forms included a THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 9 reference to pre-admission visits or to the home’s policy on emergency admissions. Each of the service users had been issued with a contract. A copy of the service users’ contract was made available for inspection. The contract still stated ‘Residence in the home for the first four weeks will be on a trial basis’. The trial period following admission should be three months. The space provided in the contract for recording details of the personal support, facilities and services to be provided specifically to the service user had not been completed. In addition, neither the service user nor her representative had signed the contract. These deficiencies should be addressed. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 The systems for assessing, recording and reviewing the service users’ needs were inadequate to ensure the safe delivery of care. EVIDENCE: The acting manager was unable to find the care plan in respect of one service user. The form that was used for reviewing the service user’s care plan dated 31 March 2005 did not include a reference to all of the aspects of care listed in Standard 2.3. There was no evidence to show that the records in the service user’s file in regard to possible self-harm, seizures and nutritional needs had been reviewed. The care plan in respect of another service user contained a reference to all of the issues listed in Standard 2.3. However, the care plan did not contain detailed guidance for the delivery of care. For example, there was a reference in the care plan dated 26 November 2004 and in the review conducted on 31 March 2005, to the need for the staff to encourage the service user to undertake ‘passive exercises and stretching movements’. However, neither of the forms included any information or guidance about the way in which the staff should carry out the exercises or their frequency. There was no recorded evidence to show whether the members of staff were carrying out the exercises. The review of the care plan dated 31 March 2005 did not cover all of the issues in the care plan and lacked clear, specific guidance to enable the THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 11 staff to meet the service user’s needs. The acting manager stated that the service user had a Behaviour Management Plan that was with the Community Behaviour Management Team. However, the acting manager did not know when it had been taken from the home or when it would be returned. The service user displayed challenging behaviour e.g. slaps, kicks, screams and shouts. However, there was no reference to any of the behaviour in the review dated 31 March 2005. During discussion with a member of staff reference was made to the needs of another service user including aspects of his behaviour e.g. self-harm, and to aspects of his care e.g. hand massage, treatment for athletes’ foot and chiropody. However, the care plan that was reviewed on 31 March 2005 did not contain any reference to any of these issues. The financial records held by the home on behalf of the service users were examined. The record of all the transactions for each of the service users had been maintained up to 31 March 2005. The records had also been independently audited and receipts were available. However, no records of any transactions had been kept since the end of March and the service users’ money was pooled. The requirement that had been made in previous inspections regarding this issue had not been fully implemented and still stands. The recommendations that were made as a result of previous inspections regarding the provision of information about the home’s policies in suitable formats for service users and the inclusion in the service users’ guide of a reference to confidentiality had not been implemented. Risk assessments had been carried out in respect of some aspects of the service users’ care e.g. going to bed, sleeping and getting up. However, in the case of one service user, there was no evidence to show that a risk assessment had been carried out in regard to self-harm. In the case of another service user there was no evidence to show that a risk assessment had been carried out in regard to falls. The requirement that was made regarding risk assessments as a result of previous inspections had not been implemented and still stands. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) N/A It was not possible to form an overall judgement as none of the Standards in this section of the report were fully assessed during this inspection. EVIDENCE: The home’s response to the two requirements and two recommendations that were made in regard to aspects of the service users’ lifestyle as a result of previous inspections was assessed. It was noted that a risk assessment had been carried out and recorded regarding the care of two of the service users at night. However, a risk assessment in respect of the care and supervision of a third service user during the night had not been carried out. The requirement in regard to this issue had not been fully implemented and still stands. The requirement that had been made previously regarding the maintenance of a detailed record of the food provided for the service users had been implemented. There was a reference to the provision of a minimum seven-day annual holiday in the service users’ contract and in the pictorial form of the service users’ guide. However, there was no similar reference in the statement of purpose or in the written copy of the service users’ guide. In practice, the service users had not been on a seven-day holiday outside the home during the previous THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 13 twelve months. The recommendation regarding this matter, therefore, had not been implemented and still stands. There was no reference to the home’s rules on alcohol and drugs in the statement of purpose or to the home’s rules on smoking, alcohol or drugs in either of the two forms of the service users’ guide. The recommendation that was made in regard to this issue as a result of previous inspections had not been fully implemented and still stands. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) N/A It was not possible to form an overall judgement as none of the Standards in this section of the report were fully assessed during this inspection. EVIDENCE: The home’s response to the four requirements and two recommendations that were made in regard to aspects of the service users’ personal and healthcare support as a result of previous inspections was assessed. The acting manager confirmed that, since the previous inspection, both of the female service users had attended the New Road Surgery for a medical examination. It was also confirmed that the three service users had undergone a dental check on 3, 10, and 17 March 2005 respectively. The requirements that were made in regard to these two issues had, therefore, been implemented. A copy of the home’s policy and procedure for the administration of medication was made available for inspection. It was noted that the requirement that had been made as a result of the previous inspection to amend the policy in accordance with the advice given in the last inspection report had been implemented. However, part of the policy that referred to ‘designated staff for the home’ had been left blank. This part of the policy must be completed. In the section that referred to errors in administration the policy should state that the CSCI must be notified in accordance with the requirements of Regulation 37. In the section headed ‘Training’ the wording ‘should be encouraged to’ should be replaced with ‘must’. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 15 The acting manager provided written confirmation to show that six members of staff would undertake appropriate training in the Care of Medicines organised by Boots on 29 June 2005. It was pleasing to note that arrangements had been made to provide the training. However, at the time of the inspection, the previous requirement regarding this issue had not been implemented and, therefore, the requirement still stands. The acting manager confirmed that the recommendation made as a result of the previous inspection to obtain a copy of the publication ‘The Administration and Control of Medicines in Care Homes and Children’s Services’ had been implemented. Similarly, it was confirmed that the recommendation that was made to discuss with the service users and their relatives and record in the service users’ care plans their wishes regarding when they grow older, become ill, terminal care and arrangements after death had also been implemented. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The home’s complaints procedure lacked important details and was not referred to consistently in other relevant documents that the home was required to provide. EVIDENCE: The home had a complaints procedure that still contained a reference to the former National Care Standards Commission (CSCI) rather than the present Commission for Social Care Inspection. The complaints procedure also contained an incorrect telephone number for the CSCI. The complaints procedure did not include an assurance that service users and their families would not be victimised for making a complaint. There was no reference to the home’s complaints procedure in the written form of the service users’ guide. The two requirements that were made in regard to the complaints procedure as a result of the previous inspection had not been implemented and still stand. Action must be taken to ensure that all the details of the complaints procedure are correct and that the complaints procedure is referred to correctly and consistently in all of the relevant documents provided by the home. The home had a complaints book. There were no entries. The home’s response to the two requirements and one recommendation that were made in regard to the protection of vulnerable adults from abuse as a result of the previous inspection was assessed. A copy of the home’s policy on abuse was made available for inspection. The requirement had not been implemented and still stands. The policy did not include any specific reference to whistle blowing or to the local social services or police contact numbers. The reference to the telephone number for the Commission for Social Care Inspection (CSCI) was incorrect. There was no reference to the Adult Protection Coordinator. There was no reference to the types of abuse that may occur. The policy should state that all evidence or suspicion of abuse must be THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 17 reported to the CSCI in accordance with Regulation 37. There was no information about the values or principles that underpinned the home’s approach to abuse. The reference to ‘patient’ should be changed to ‘resident’ or ‘service user’. The home’s policy and procedure on whistle blowing was not made available for inspection. Therefore, it was not possible to assess whether the requirement and recommendation that were made regarding the policy and procedure on whistle blowing had been implemented. The requirement and recommendation still stand. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28 and 30 The home provided a comfortable and homely environment and some improvements had taken place since the previous inspection. However, further improvements need to be made to various aspects of the environment in order to ensure the safety and comfort of the service users. EVIDENCE: The home was accessible. There was a ramp leading to the front door to enable easy access for people who use a wheelchair. The amount of living space was adequate for the three service users for whom the home was registered. The amount of space provided met the standard for homes that were registered prior to 1 April 2002. The premises were suitable for their stated purpose, clean, comfortably furnished and free from offensive odours. The home had its own dedicated, transport i.e. a seven-seat people carrier. The vehicle was used for transporting the service users. The home had begun the process of implementing recommendations arising from a recent inspection of the premises by the Fire Safety Officer. Several important items of work to improve fire safety within the premises had not been completed e.g. the installation of fire doors. The registered provider gave an assurance that all the work to improve the home’s fire precautions would be completed by the end of June. The acting manager stated that she had spoken to the THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 19 Environmental Health Officer regarding the home’s risk assessment on infection control. The acting manager said that she had been advised that the risk assessment was satisfactory. The acting manager also confirmed that she had addressed all of the issues referred to in the letter from the Environmental Health Officer dated 19 February 2004. The home maintained a ‘Maintenance Required and Household Purchase Request Book’. The book had been introduced on 18 April 2004 and included a record of the items that had been replaced and/or repaired within the home. The registered provider and acting manager were requested to include in the book all of the items that were due for maintenance or repair/renewal in the coming year and to record the date when the item had been replaced or the work completed. Each of the three service users had their own single bedroom. The amount of space in all three bedrooms was adequate. One of the bedrooms had a sitting area. None of the service users required the permanent use of a wheelchair. Two of the service users required a wheelchair for use outside the premises. A referral had been made for one of the service users to be supplied with a new wheelchair. The furniture and fittings in the bedrooms were generally sufficient and suitable for the service users’ needs. However, one of the bedrooms did not have a wardrobe or any curtains. The acting manager said that these items were in the process of being provided. The acting manager also stated that a risk assessment had been undertaken in respect of one service user that was registered blind. A table and chair had not been provided in her bedroom as a result of the risk assessment. Two comfortable chairs had not been provided in the bedrooms of the other two service users. There was no record in either of the two service users’ files regarding this matter. All of the items of bedroom furniture listed in Standard 26.2 must be provided unless a risk assessment has been carried out and recorded and the items have not been provided because they posed a potential risk. The service users’ bedrooms were lockable. The window in one of the service users’ bedrooms on the first floor was not fitted with an opening restrictor. The requirement that was previously made regarding the items that must be provided in the service users’ bedrooms had not been implemented and still stands The service user that was accommodated on the ground floor had an en suite bathroom containing a hoist, wash hand basin and a toilet. There were two bathrooms on the first floor. Both bathrooms contained a toilet and a wash hand basin. The two service users, therefore, that were accommodated on the first floor also had exclusive use of their own bathroom and toilet. The bathrooms were lockable. There was a separate toilet on the ground floor that was used by staff and visitors. The home had an enclosed rear garden with a lockable side gate. The home also had kitchen and laundry facilities that were domestic in scale. The shared space included a combined dining room and lounge, a snoozelen and a THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 20 conservatory. The home had an office that was used for private discussions and consultations. The home had a ‘no smoking’ policy. None of the service users smoked. Any staff members that smoked were allowed to smoke outside. The home had a staff sleeping-in room and adequate facilities to enable staff to store their personal belongings. The conservatory had still not been provided with ramped access. The radiators throughout the home and the exposed pipe-work in the laundry had not been guarded. Standard 29 was not fully assessed during this inspection. However, it was noted that an occupational therapist had recently assessed the use of one of the bathrooms on the first floor by one of the service users. The occupational therapist had recommended the installation of a hoist and the provision of grab rails for the benefit and safety of the service user and staff. The premises were clean and free from offensive odours. The home had a satisfactory infection control policy. The laundry facilities were satisfactory and included an appropriate washing machine. Since the previous inspection the laundry ceiling had been painted. The exposed pipe-work in the laundry must be boxed. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 36 The number, recruitment, induction and supervision of staff was insufficient to ensure a consistent standard of care. EVIDENCE: Three members of staff had not undertaken training in the protection of vulnerable adults from abuse i.e. ‘Abuse in the Care Home’. The requirement, therefore, that was made as a result of the previous inspection in regard to adult protection training had not been fully implemented and still stands. Three members of staff were undertaking NVQ level 2 training and one member of staff was undertaking NVQ level 3 training. One member of staff had undertaken training in social work and one member of staff had completed NVQ level 2 training. The recommendation that was made as a result of the previous inspection in regard to NVQ level 2 training still stands. The home employed both male and female staff. The staff members were from different cultural/ethnic backgrounds. The manager confirmed that regular staff meetings were held. A staff meeting was held on the first day of the inspection. Specialist services were obtained from outside agencies, if necessary, to support the work of the staff in the care of the service users. In addition to the manager, the home employed a further eight members of staff. One of the eight staff members was a senior support worker and the other seven members of staff were employed as support workers. The eight THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 22 members of staff were contracted to work a total of 271 hours per week. The home did not employ any laundry or catering staff. The support workers were employed to undertake all of these duties in addition to their direct care work with the service users. No administrative support was provided. The acting manager was expected to carry out all such duties as part of her management responsibilities. It was confirmed that, between 26 September 2004 and the end of December 2004, four members of staff had left the home. The acting manager stated that the home had vacancies for the equivalent of three fulltime support workers and a part-time cleaner. The acting manager stated that, because of the shortage of staff, she was often required to work as a ‘carer’ and to cover the support workers’ shifts. This was the case on the first day of the inspection. The acting manager stated that she spent at least 50 of her time on caring duties. Both the registered provider and the acting manager stated that the home encountered ‘great difficulties’ in recruiting staff. They confirmed that the home was currently advertising for staff. In addition to the current staffing shortage, three of the existing staff had recently given notice of their intended resignations due to take effect within a few weeks of the date of the inspection. Ways to overcome the staffing problems were discussed with the registered provider and the acting manager during the inspection. The duty rota contained the names of former staff. The names had been crossed out and replaced with the names of staff that had been appointed more recently to the home. The senior support worker was designated on the rota as a support worker. The staff duty rotas that were made available for inspection did not contain any evidence e.g. the acting manager’s signature, to show that the hours specified had been worked. The two requirements that had been made previously regarding the staff rota still stand. It was also noted that staff were still being required to work long shifts i.e. twelve and thirteen hours. The home had an equal opportunities policy. There was evidence to show that most of the staff had been issued with a copy of the policy and also with a copy of the code of conduct and practice set by the General Social Care Council. However, the recommendation that had been made previously to include a reference to the home’s equal opportunities policy in the service users’ guide had not been implemented. The staff files were inspected. Most of files contained most of the relevant information. However, three files did not contain a photograph. Two files did not contain any proof of identity. One member of staff who was below the age of 18 years was employed as a ‘trainee support worker’. The acting manager stated that the trainee was not involved in the provision of any personal care. The file for the trainee did not contain a job description or a contract. The file of another member of staff that had been appointed in May 2004 contained only one written reference. The requirement that was made as a result of previous inspections regarding induction and foundation training had not been implemented. One member of THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 23 staff that had commenced working at the home on 28 February 2005 had not undertaken the relevant induction training. The requirement still stands. A record of the training that had been undertaken by the staff was being maintained. However, there had been limited discussion regarding training in the staff supervision meetings and no assessment of the effectiveness of staff training had been carried out. The requirement that was made as a result of previous inspections regarding the provision of individual training and development assessments and profiles had not been implemented. The requirement still stands. Although the home had a suitable form on which to record a training and development plan for the staff team as a whole, the form had not yet been completed. Therefore, the recommendation that was made as a result of previous inspections regarding this issue still stands. The staff files also showed that supervision meetings were not being held at regular or frequent intervals. One staff member had attended only one supervision meeting since 29 December 2003. Another member of staff had attended only one supervision meeting since 16 September 2004. Two staff members, both of whom were appointed in November 2004, had attended only one supervision meeting since the date of their appointments. In the case of three members of staff, one of whom had been appointed on 20 December 2003, there was no record of any supervision meetings since the date of their appointments. It was also noted that the form that was used for recording supervision did not include all of the relevant issues as listed in Standard 36.4. There was no record in the staff files of any appraisals. The manager confirmed that neither she, nor any of the support workers, had undergone an annual appraisal. The manager also confirmed that none of the staff had been issued with a copy of the home’s written grievance and disciplinary procedures. The manager was advised that any issues relating to alleged offences involving members of staff must be fully discussed. A detailed record of the outcome of such cases and any decisions arising from the discussions must be maintained. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 24 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38 The lack of leadership in the management of the home and the lack of cohesion and direction amongst the staff has resulted in a failure to assure the quality of the service provided. EVIDENCE: The home did not have a registered manager. The acting manager had been in post since December 2003. The acting manager confirmed that she had successfully completed the Registered Managers’ Award training in January 2005 but she had not been registered and, hence, authorised by the Commission to be managing the home. The registered manager’s job description did not reflect all of the responsibilities outlined in Standard 37.3. Therefore, the recommendation regarding this issue that had been made as a result of previous inspections still stands. The acting manager stated that she was unable to devote sufficient time to the management aspects of the home. She stated that, because of the shortage of staff, approximately 50 of her time was spent in carrying out care-related THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 25 tasks. Four members of staff had left the home within the previous six months. In addition, three members of staff had recently given notice of their intention to leave. The registered provider and the acting manager stated that a division had developed within the staff group between the experienced members of staff and the less experienced members of staff. This had created ill feelings and a lack of cohesion amongst the staff group as a whole. The acting manager said that differences had arisen between members of staff over ‘petty things that created an atmosphere’. The registered provider stated that he intended to interview the members of staff that were leaving in order to find out more precisely what their concerns were. The registered provider also accepted the recommendation that staff training in the form of team building should be provided in order to improve staff relationships and staff morale and create a greater sense of cohesion and direction. Staff feedback forms had been issued to the staff on 12 May 2005. However, questionnaires for issuing to the service users’ relatives had not yet been developed. The previous recommendation regarding the home’s management and practice had not been implemented. The requirement regarding the introduction of a quality assurance system and the recommendation regarding an annual development plan, both of which were made as a result of previous inspections, had not been implemented and still stand. The recommendation that was made as a result of previous inspections that evidence should be provided to show that the staff have read and understood all of the home’s policies and procedures had not been implemented and still stands. The requirement that was made as a result of previous inspections regarding the records that must be maintained within the home had not been fully implemented. For example, the staff files were not being accurately maintained, there was no report of any visit made in accordance with Regulation 26 during April 2005 and the statement of purpose and service users’ guide were still incomplete. The CSCI had not received a copy of the report made in accordance with Regulation 26 for February, March, April or May 2005. The requirement, therefore, still stands. The tests of all the fire safety equipment, fire drills and staff instruction were being maintained. The previous requirement that was made regarding this matter had been implemented. Evidence was provided to show that an electrical safety check had been carried out on all portable appliances. The previous requirement that was made regarding this matter had been implemented. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 26 The acting manager confirmed that risk assessments had been carried out and recorded for all safe working practice topics in accordance with the requirement that had been made previously in regard to this matter. It was noted that several members of staff had not undertaken relevant training in a number of areas. Only one member of staff had a valid first aid certificate. Three members of staff had not undertaken any training in moving and handling or food hygiene. Two staff had not undertaken any formal training in fire safety. None of the staff had undertaken any up to date training in epilepsy awareness. Four staff had not undertaken any training in the administration of rectal diazepam. Five members of staff had not undertaken any training in equal opportunities. It was noted that a window in one of the service users’ bedrooms on the first floor did not have a restrictor. This deficiency must be addressed as a matter of priority. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 1 1 x 2 2 Standard No 22 23 ENVIRONMENT Score 2 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 1 3 2 3 2 x 3 Standard No 11 12 13 14 15 16 17 x x x x x x x Standard No 31 32 33 34 35 36 Score x x 1 1 x 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 THE HAWTHORNS Score x x x x Standard No 37 38 39 40 41 42 43 Score 1 1 x x x x x E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 28 Yes Are there any outstanding requirements from the last inspection? 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 1 Regulation 4 Requirement The statement of purpose must be amended so that it includes all of the information detailed in regulation 4 and Schedule 1. (Previous timescale of 31 January 2005 not met A service users guide which includes all of the information detailed in Regulation 5 and Standard 1 must be available in the home and copies must be given to all current, and any prospective, service users and their families. (Previous timescale of 31 January 2005 not met). The form that is used by the home for assessing the care needs of service users must be amended in accordance with the requirements of Regulation 14, Standard 2 and the guidance given in this report. (Previous timescale of 31 January 2005 not met). Service user plans that cover all aspects of care as set out in Standards 6 and 2.3 must be drawn up with the involvement of each service user, and in a format that can be understood E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Timescale for action 30 June 2005 2. 1 5 30 June 2005 3. 2 14 30 June 2005 4. 6 15 30 June 2005 THE HAWTHORNS Version 1.30 Page 29 5. 7 17 6. 9 12,17 7. 16 12,17 8. 20 18 9. 20 18 by or explained to the service user. All service user plans must contain clear, specific guidance for staff to enable the safe delivery of care, be reviewed at least every six months and updated to reflect the service users changing needs. (Previous timescale of 31 January 2005 not met). The financial records held on behalf of service users, including all incoming and outgoing payments, must be accurately maintained and regularly, independently audited/monitored in accordance with Regulation 17, Schedule 4.9 and Standard 7.7. (Previous timescale of 31 January 2005 not met). A risk assessment must be carried out in respect of each service user with particular regard to their behavioural needs in discussion with the service user and any relevant specialists and risk management strategies agreed, recorded in their individual plans and reviewed. (Previous timescale of 31 December 2004 not met). A risk assessment must be carried out in respect of the level of care and supervision/monitoring required by each service user during the night and the outcome and any action taken to minimise the risks recorded in their individual care plans and reviewed. (Previous timescale of 31 December 2004 not met). The policy and procedure for the administration of medication must be amended in accordance with the guidance given in this report. Accredited training in the 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June Page 30 THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 10. 22 22 11. 22 22 12. 23 12,13 13. 23 12,13 administration of medication must be provided for all the staff that includes basic knowledge of how medicines are used and how to recognise and deal with problems in use; and the principles behind all aspects of the homes policy on medicines handling and records. (Previous timescale of 31 March 2005 not met). The complaints procedure must be amended to include a clear statement that complaints can be referred to the CSCI at any stage, if a complainant wishes to do so and an assurance that service users and their families will not be victimised for making a complaint. (Previous timescale of 31 December 2004 not met). The complaints policy and procedure must include the full name, address and telephone number of the area office of the CSCI and an appropriate reference to the complaints policy and procedure must be included in both forms of the service users guide. (Previous timescale of 31 December 2004 not met). The policies and procedures on abuse, the protection of service users and whistle blowing must include the full name, address and telephone number of the CSCI, a statement that all cases of suspected or alleged abuse must be reported immediately to the CSCI and/or the Adult Protection Coordinator and information regarding the types of abuse that may occur. (Previous timescale of 31 January 2005 not met). The homes policy and procedure on whistle blowing must be 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 Page 31 THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 14. 24 23 15. 26 16 16. 28 13 17. 28 13 18. 29 13,23 19. 32 18 reviewed and revised in accordance with the Public Interest Disclosure Act 1998 and the Department of Health guidance No Secrets in order to ensure that it contains all of the relevant information. (Previous timescale of 31 January 2005 not met). All of the outstanding fire safety precautions as specified in the Fire Safety Officers letter dated 2 February 2005 must be fully and satisfactorily completed. All of the items of furniture specified in Standard 26 must be provided in rooms occupied by service users. If the provision of any item poses an unacceptable risk to the service users or they decline the provision, details of the discussions and decision about this should be recorded in the assessment of the service users needs. (Previous timescale of 31 December 2004 not met). The conservatory must be provided with ramped access to the rear garden and fixed radiators that are guarded or have guaranteed low temperature surfaces. (Previous timescale of 31 March 2005 not met). Exposed pipe-work, including the laundry, and radiators throughout the home must be guarded or have guaranteed low temperature surfaces. (Previous timescale of 31 March 2005 not met). A suitable bath hoist and grab rails as recommended by the occupational therapist must be provided in the bathroom on the first floor. All of the staff must undertake 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June Page 32 THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 20. 33 17 21. 33 17 22. 33 18 23. 34 19 24. 35 12,18 25. 35 18 26. 36 18 training in the protection of vulnerable adults from abuse. (Previous timescale of 31 March 2005 not met). The duty rota must show which members of staff are on duty at any time of the day and night, including the manager, and in what capacity. (Previous timescale with immediate effect not met). An accurate record must be maintained of whether the staff duty rota was actually worked. (Previous timescale with immediate effect not met). Suitably qualified, competent and experienced staff must be employed to work at the care home at all times in such numbers as are appropriate for the health and welfare of the service users. The homes staff recruitment and appointment procedures must be improved in accordance with Regulation 19 and Standard 34. All members of staff must receive induction and foundation training to National Training Organisation specification within 6 weeks and 6 months of appointment to their posts, respectively. (TOPSS and LDAF) (Previous timescale with immediate effect not met). All staff must have individual training and development assessments and profiles. (Previous timescale of 31 January 2005 not met). Care staff must receive formal supervision at least 6 times a year, which includes all of the issues referred to in Standard 36.4. (Previous timescale of 31 March 2005 not met). 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 30 June 2005 THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 33 27. 39 28. 41 29. 42 30. 42 31. 42 32. 42 33. 42 A quality assurance system must be introduced in accordance with the requirements of Regulation 24 and Standards 39.3, 39.4, 39.6 and 39.7. (Previous timescale of 31 March 2005 not met). 7,9, 17,19 All the records required by Regulation as specified in Schedules 2, 3 and 4 must be maintained securely in the home and used in accordance with the Data Protection Act 1998. (Previous timescale of 31 March 2005 not met). 26 Visits to the home by the registered provider must take place at least once a month and a copy of the written report on the conduct of the care home supplied to the Commission and to the registered manager in accordance with Regulation 26. 13,18 There must be at least one member of staff on duty at all times, day and night, who is qualified in first aid i.e. First Aid at Work. 13,18 All staff must receive updated training in moving and handling, food hygeine, epilepsy awareness, the administration of rectal diazepam and fire safety. 13,18 All staff must receive equal opportunities training, including disability equality training provided by disabled trainers; and race equality and antiracism training. 13 An opening restrictor must be fitted to the window in one of the service users bedrooms on the first floor. 24 30 June 2005 30 June 2005 30 June 2005 31 July 2005 31 July 2005 30 September 2005. 18 May 2005 THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 34 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 4 Good Practice Recommendations Details of the homes practice regarding pre-admission visits, a minimum three month settling-in period for new service users and the homes no emergency admissions policy should be included in both the written and pictorial form of service users guide. The service users contracts should include a reference to a minimum three-month trial period following admission. The reference in the contracts to the first four week trial basis should be deleted. The service users contracts should be amended in accordance with the guidance given in this report and signed by the service users and/or their representatives. The home should provide service users with comprehensive, accessible, understandable and up-to-date information, in suitable formats, about its policies, procedures, activities and services, and appropriate communication support. An appropriate reference to the homes policy and procedure on confidentiality should be included in the service users guide. The service users should have, as part of their basic contract price, the option of a minimum seven-day annual holiday outside the home (or, where appropriate, a suitable equivalent alternative) which they help choose and plan. The homes rules on smoking, alcohol and drugs should be clearly stated in the terms and conditions of residence (contract), the service users guide and in the staff contracts. The wording of the homes policies on the protection of service users and whistle blowing should be reviewed and, where necessary, revised in order to ensure that they state what the staff will do to implement the policies. The book that is used for recording items that have been replaced or repaired should include all the items that are due for maintenance/renewal for the coming year and the date when the work/item had been completed or addressed. Arrangements should be made for staff to receive training E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 35 2. 5 3. 4. 5 8 5. 6. 10 14 7. 16 8. 23 9. 24 10. 32 THE HAWTHORNS 11. 12. 13. 14. 15. 16. 17. 18. 19. 33 34 35 36 36 37 38 38 38 20. 21. 39 40 that will enable a minimum of 50 of the care staff to attain a qualification at NVQ level 2 or equivalent by 31 December 2005. The practice of staff working long shifts e.g. twelve and thirteen hours, should be discontinued. The homes equal opportunities policy should be referred to in the service users guide. The home should have a training and development plan. All staff should undergo an annual appraisal with their line manager to review performance against job descriptions and agree career development plans. All of the staff should be issued with a copy of the homes written grievance and disciplinary procedures. The registered managers job description should be reviewed and revised in order to reflect all of the responsibilities outlined in Standard 37.3. Team building training should be introduced in order to improve staff relationships and staff morale and to create a greater sense of cohesion and direction. The home should develop its own questionnaire for issuing to the service users relatives. The way in which the homes management planning and practice encourage and reward innovation, creativity, development and change should be formalised and made clear to all the staff. There should be an annual development plan for the home based on a systematic cycle of planning, action, review, reflecting aims and outcomes for service users. Evidence should be provided to show that the staff have read and understood all of the homes policies and procedures. THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 36 Commission for Social Care Inspection The Coach House John Comyn Drive, Perdiswell Park Droitwich Road, Worcester WR3 7NW National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI THE HAWTHORNS E52 S35065 The Hawthorns (Wychbold) V226290 110505.doc Version 1.30 Page 37 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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