Inspection on 12/01/07 for Hawthorns, The

This inspection was carried out on 12th January 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, The 22/12/08

Hawthorns, The 16/10/05

Hawthorns, The 22/06/05

Hawthorns, The 05/10/04

Hawthorns, The 23/04/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Hawthorns, The 29 Rotton Park Road Edgbaston Birmingham West Midlands B16 9JH Lead Inspector Jill Brown Key Unannounced Inspection 09:10 12th January 2007 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, The DS0000017037.V326693.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, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorns, The Address 29 Rotton Park Road Edgbaston Birmingham West Midlands B16 9JH 0121 455 9024 0121 454 5375 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) Mr John Holcroft Jnr Ms Linda Smith Care Home 22 Category(ies) of Old age, not falling within any other category registration, with number (22) of places Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th October 2005 Brief Description of the Service: The Hawthorns is a care home providing personal care and accommodation for up to 22 older people. It is privately owned by Mr John Holcroft and is situated in a residential area of Birmingham close to a variety of community resources. The property is a large three storey detached building. There is a stair lift in place covering all the stairs. There are bedrooms on all three floors. The lounge space is arranged to give two connecting sitting rooms. Smoking is allowed in the conservatory that overlooks the rear garden. There is a dining room off the kitchen and the home’s laundry is located off the dining room. There are a number of baths and showers throughout the home. Some aids and adaptations are available in the home. There is a mature and pleasant garden to the rear of the property with a fishpond that is fenced off for reasons of safety. The garden is accessed via steps, and a steep ramp. The home currently charges between £305.00 and £340.00 per week and this is likely to change in April 2007. Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. An unannounced key inspection took place on a day in January. The inspection took approximately 8 and half hours and looked at the majority of the 38 standards. During the inspection 4 residents, 3 relatives, the registered manager and the administrator were spoken to. The inspector looked at: - 2 resident’s care records in depth and sampled another, two staff files, medication records and a number of medications, and toured areas of the building. Some of the home’s records were looked at including staff training records, maintenance and inspection of services such as gas, electricity and fire safety. Before the inspection the inspector received 7 comment cards from relatives, 10 from residents and 2 from health professionals. The home submitted some information including the pre-inspection questionnaire, staff rotas and menus. The Commission receives information from the home about any incidents and this with the above information forms the basis of this report. The home and the Commission have received no complaints about the home’s performance since the last inspection. What the service does well: All residents at the home have a contract that states the home’s terms and conditions of residents’ stay. The home undertook an assessment of resident’s needs before coming into the home. This assessment contained information about residents health, personal care concerns and how the resident liked to have their care delivered such as the time they prefer to go to bed and so on. This information helped the home instruct carers. The home had good relationships with health professionals and one Community Psychiatric nurse said that the home gave ‘good feedback’ and ‘refers concern to appropriate professionals when they arise.’ The home’s medication administration was good which helps residents well being. The home had information about the type of medication they were giving and checks were in place to account for medicines. Residents and relatives thought that staff treated them well with comments such as ‘staff are supportive’ ‘happy with the care here’ being made. The home Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 6 provided a homely atmosphere and relatives said that they felt comfortable visiting. Residents could spend time in their bedroom if they wished and a number of the residents had televisions in their rooms. The home had enough staff, half of the care staff having a NVQ2 in care. The home has an experienced and qualified manager and the owners are involved in the day-to-day running of the home. The required checks to ensure safety of the building such gas inspection, electrical wiring inspection and fire safety have been completed. What has improved since the last inspection? What they could do better: The home needed to keep on residents’ files copies of letters to residents or their representatives when they had informed them about changes in the home’s fees. In some cases the residents information in the personal profiles needed to be included in the care plans to ensure that residents have the care delivered in the way that they would wish. Risk assessments needed to be more detailed so that risks could be better managed. For example the home needed to show when a resident may be most at risk of falling, such as is because they cannot manage uneven surfaces or because they have trouble gaining their balance when rising from a chair. Whilst residents did not comment on the lack of opportunity for activities or choice of meals the comment cards sent back showed less satisfaction in these areas. The home were not showing by their menus or by their recording how they assisted residents to have active choices especially if the residents had some memory impairments. Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 7 The home need to improve its quality assurance systems to pull together small issues raised with the home, relative and residents views, building decoration and refurbishment, analysis of falls and accidents and so on to produce a plan of improvement for the next year. Whilst the home’s environment was homely and comfortable there were signs that a room-by-room check was needed to maintain a good standard. The kitchen needed refurbishment as the unit doors had exposed chipboard, which makes it difficult to clean, one mattress in a room sampled needed to be replaced, hot water delivery in two areas was slow and decoration of bedrooms needed to be considered not just at re-letting times. All these actions need consideration and action to ensure resident’s comfort. The home needed to ensure that all care staff have updated training in Moving and handling as this needs to be yearly, a number of staff need to have First Aid training repeated. One member of staff and been appointed without a Protection of Vulnerable Adults check although this person had recent clearance from another home all new starting staff must have had this check cleared before they can work within the home. These actions are needed to ensure everyone’s safety. 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, The DS0000017037.V326693.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, The DS0000017037.V326693.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): 2,3,4 & 5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home assessed residents and invited them for trial visits before places at the home were offered. Residents could be assured that their needs would be met. Residents were protected by a contract outlining terms and conditions of their stay. EVIDENCE: The home had contracts for residents available for inspection these were not updated on a yearly basis. The administrator of the home said that residents that were privately funded receive a letter telling them of the change in the cost of the home. There were no copies of letters on residents’ files to confirm this. However residents that are part funded by the local authority the home expected the local authority to advise their residents of changes in the assessed charge or terms and conditions. Comment cards from residents said they received enough information about the home although a number thought Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 10 they may have forgotten and the majority thought they had received a contract. The records of two residents showed that residents had an assessment and a trial visit to the home before admission. The assessment included information about the new resident’s disabilities, health conditions and personal care needs. The home also collected information on allergies and whether residents experienced pain on regular basis and this is commended. Assessments contain information about residents place of birth, religion and methods of communication; this helps the home plan for residents’ diverse needs. One resident was observed to be gaining solace from reading a bible and spoke to the inspector about psalm 23. The home has begun to advise relatives and residents whether they can meet the needs of residents, letters seen were not dated and this made it difficult to assess whether these were done before admission. Hawthorns, The DS0000017037.V326693.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 &10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home had good instructions to staff how to provide care for residents. More detailed risk assessments would improve the planning to minimise risks to residents. The home liaised well with health care professionals to meet residents’ health care needs. Medication administration was generally well organised with checks to ensure that residents health was maintained. Residents and their relatives thought that residents were well cared for and that staff treated them with respect. EVIDENCE: The home undertook a number of risk assessments on residents including risks of falls, moving and handling and mobility these could be in more detail to Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 12 show where the risk lay. For example was the resident at risk of falling when getting up from a chair or going to the toilet on the night, this would enable appropriate measures to be put in place. A resident that smoked had a risk assessment that did not have information about what part of the smoking process was risky for them, for example was the resident safe with a lighter, lighting a cigarette, smoking a cigarette and extinguishing it? Did the resident have the money to smoke as often as they wished? Did the resident give lighters and so on to other residents who could not manage them safely? The home needed to record the outcome and measures to main safety of smoking for the resident and others. Care plans were not always detailed enough to ensure that care was delivered in a way that the resident would wish. However the home also completes personal profiles and these filled in the gaps in information. The personal profile contained information that showed a residents’ life experience and this is important as it helps maintain the resident as a person for the people providing the care. The manager of the home said that they intended to ensure care plans also had these details and this would make the care plans easier for newer staff to use. One care plan contained information for staff about how to approach a specific resident if the resident refused care and this ensured a consistent approach by staff. The manager summarised the care received on at least a monthly basis and the care plan was altered if necessary. Residents were weighed on admission to the home. Three residents weights were sampled and viewed over their stay at the home. The resident with the lowest weight maintained that weight and did not fluctuate, the other two lost weight. This weight loss was not concerning due the residents weight before admission. Weight loss for one of these residents was checked with the GP. Residents had assessments of their nutrition being at risk. Residents had assessments of whether they were at risk of developing pressure areas. The home had individual pressure relieving equipment that was supplied when this was of concern. Residents in the lounges appeared to have their walking aids available to them. The home had good relationships with the GP surgery, district nurses and other health care professionals. A comment card from A GP raised no concerns and a comment card from a Community Psychiatric Nurse said ‘the staff there (at the Hawthorns) have demonstrated a calm professional approach in their interactions and care delivery. There is frequent clear feedback and concerns are directed at appropriate professionals as soon as they arise. They offer a level of care and meet the needs of service users that are not able to be managed in residential care otherwise.’ Residents have access to chiropody if they wish. Residents appeared to be appropriately dressed in styles that residents preferred. Residents’ hair and nails were generally appropriately attended to. Residents that had not, had refused and this was clear in their care plans. One Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 13 relative noted that occasionally their relative was not dressed well and that spectacles were always going missing. The inspector noted that three pairs of glasses had been collected by a resident and placed in the dining area. These concerns could be addressed by seeing how often they happen and look at measures to minimise recurrence (see standard 16) Four residents’ medication was looked at and medication was found to be well organised stored and correctly accounted for in most cases and this ensured the health of residents. Photos were kept with the Medication Administration record (MAR) and this assists staff in confirming that medication was given to the right person. Copies of prescriptions were kept with the MAR this acts as another check that the medication is correct. A number of medications were supplied in blister packs that ensured that medication is given at right time to each resident and administration of this medication was correct. Liquid medications looked at appeared correct. Drugs that could not be put in the blister pack system were generally correct except for paracetamols in two cases. The home keeps the information that arrives with the medication for reference and has a quick checklist of medication which condition the medication is for and this is good practice. The homes training matrix shows that the majority of care staff have had medication training and this training was supplied for new staff. The homely medications were appropriately accounted for. Staff were observed treating residents appropriately during the inspection. Ten comment cards from residents were received by the inspector prior to the inspection and they said ‘Staff are supportive,’ ‘happy with the care here,’ ‘I appreciate the concern of the staff, everyone is so friendly’. Comment cards appeared to be completed by residents. Relatives spoken to said that staff offered to assist the resident to the bedroom on their visits so they could see the resident in private. Relative comment cards noted that the staff were friendly and the Hawthorns was a homely place. Hawthorns, The DS0000017037.V326693.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 & 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home provided activities residents did not feel there was always enough to keep them occupied. Meals these did not provide enough choice and were not varied enough to enhance residents lives. Residents were not restricted in their movement in the home and relatives were made to feel welcome and involved in their relative’s care. EVIDENCE: Whilst residents on the comment cards generally showed high satisfaction with the home, areas of activities and meals tended to score more in the ‘usually’ and ‘sometimes’ category than the ‘always’ good section, although residents raised no specific areas of concern. One resident thought their ‘blindness’ restricted their access to activities. Relatives thought that activities could be improved. Two residents care records did not demonstrate that structured activities took place since the New Year. Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 15 The home were not recording in a way that showed that individual residents had undertaken activities. A number of residents spent most of their time in the rooms and some record needs to be kept of their interaction with staff. Relatives said that they were made welcome in the home. A number of relatives said they were almost without fail offered a drink of tea or coffee when they were here. One relative said that they did not feel as if it was an intrusion being in the home where they had felt this in another home. One relative said that all the staff were patient with their relative that has dementia. Relatives said that when they asked staff were able to tell them about the care of their resident. Residents in the home had the freedom to move about the home. A number of residents spent time in their bedrooms. Residents had their walking aids available to them on this inspection. A number of residents needed assistance with buying clothing and a discussion was about how residents’ choice in this could be improved. The Commission received two weeks of menus prior to the inspection. The menus suggested that on any day soup and jacket potatoes were available as an alternative to the lunchtime meal. The inspector was advised that these were also options at teatime if the resident did not wish to have sandwiches. These alternatives to the meal offered may become boring and other alternatives needed to be explored. The home had large supplies of fresh, frozen and dried food. The kitchen kept records of residents’ birthdays and special requirements for diet and this enabled the home to ensure that food could be provided in an individual way. Residents spoken to said the food was all right however a more formalised choice a meal times is required to enable residents with memory difficulties have a full choice. Menus on tables, picture representations of menus would assist. Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. 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. The home had made arrangements to ensure good practice in regards to complaints and protection of residents. Further improvements in recording small concerns would assist the home further in improving. EVIDENCE: The home has had no complaints and the Commission has not received any about the service in this home. A small number of relatives indicated on their comment cards that they did not know the home’s policy on complaints. The home has a complaint procedure on display and has a service user guide in bedrooms but should consider a small pack of information that relatives can take away, which they can refer to when needed. Relatives spoken to said that the management of the home were open and would listen to any concerns and resolve small issues as needed. The inspector advised to record these concerns to ensure issues such as misplacing of spectacles can be quantified and a system set up to minimise the effects. The home has not had any adult protection issues raised and the Commission has not been consulted about any concerns. The home supplied a training matrix, which stated that the majority of staff had received training on adult protection. This training assists staff to ensure that they recognise when any actions to a resident could be abusive. The home ensured that new staff Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 17 receive a copy of the General Social Care Council’s Code of Practice and this ensured that staff were aware of good practice. Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,24 &26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home was generally homely and comfortable the home needed to ensure that all areas of the home are routinely checked for wear and tear to maintain a good standard. EVIDENCE: The home continued to provide care in a homely and comfortable environment. There was an ongoing programme of decoration in the home. The kitchen area needed to be refurbished cupboard doors were now showing signs of age and there were small areas where there was exposed chipboard and this makes it difficult to clean. There was enough communal space available for residents in the form of one lounge, and a smaller sitting area between the lounge and the conservatory. Residents used the conservatory as a smoking area. The area between the Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 19 lounge and conservatory was also used to access the two bathing facilities. The sizes of these rooms only allowed the seating to be arranged against the walls. There was also a separate dining room off the kitchen. The inspector was advised that the decoration was beginning and that the carpet in the dining area had been replaced. There were adequate numbers of toilets close to the lounges and dining rooms. There was an assisted bathing facility on all floors. Whilst there were sufficient facilities on each floor the home needs to consider improvements for the future as residents’ needs change and a number of the bathing areas are small and difficult shape because of the home being in an old building. At this point the speed at which hot water is delivered to some bathing and hand basins could be improved. The hot water appeared to be restricted appropriately on the hot water outlets sampled. A number of shower chairs did not have the appropriate stoppers in to prevent accidental trapping of skin and a number was given where supplies could be purchased. The inspector was informed that the home decorated bedrooms when rooms were re-let this included furniture and so on being checked. The inspector advised that the home needed to ensure that all rooms were checked as a number of residents may be long term residents and may miss the benefit of rooms being re decorated. This needed to be part of the homes quality assurance plan. Residents’ rooms were personalised and for the most part decorated in a homely style. One resident’s room sampled had a mattress that was coming to the end of its life and the baseboard was beginning to be felt through the mattress, this potentially could be uncomfortable for the resident. A number of duvets were water impermeable and this is important if the resident was incontinent, a number of pillows seemed past their useful life and wipeable pillows would be a good idea. The lighting was not inspected on this occasion. There were records of fridge and freezer temperatures for where food was stored. Food was dated at the point it was placed in the freezer or fridge. The one area where there was an odour control issue at the last inspection had been resolved for the most part by removal of vanity unit around the sink. The cellar door did not have a lock that could be opened from the inside of the cellar. Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 &30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Whilst the home had appropriate levels of staff and staff trained to basic NVQ 2 in care a number areas of training needed to be updated to ensure that residents have the benefits of current care practice. EVIDENCE: The home supplied examples of the staff rotas prior to the inspection. Unfortunately it was not possible from these rotas to determine how many care staff were undertaking caring tasks. The home has a number of staff that undertake both care and cooking tasks. The inspector was advised that where a member of care staff was undertaking cooking duties they would do so for the whole shift. It would appear that the home plans to have at least three care staff on duty throughout the day supported by domestic care, cook and management on a week days and a cook at the weekends. This level of staff appeared to meet the needs of the current residents. The staff had achieved a target of 50 of the care staff being trained to NVQ Level 2 or above. Two staff personnel files were looked at. The home had accepted a member of staff with the Criminals Records Bureau check undertaken by the previous employer and although this check had been done recently this did not meet Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 21 required practice. The other staff member had the appropriate checks undertaken. The home had copies of the General Social Care Council Code of practice and stated that these were given out to each new member of staff and this could be usefully noted on each staff members file. This code of practice ensured that staff know not only what is accepted staff behaviour by the home but also by the professional body that governs care practice. The home provided the inspector with a matrix of staff attendance at required training the inspector noted that the majority of staff had attended the majority of training however the Moving and Handling course needed to be updated for all staff and a number of staff needed a repeated First Aid training course. Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home was managed well with a management team that were involved in meeting the needs of the residents. The management ensured that appropriate maintenance and inspection of services such as gas and electric and fire safety were undertaken to maintain the safety of residents. Improvements could be made in the homes forward planning to ensure that a high standard is always maintained. EVIDENCE: The manager told the inspector that she had completed the Registered Managers Award and this was displayed in the home. The home also has a post head of care that looks at the quality of care provided to residents. Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 23 Although the registered person carries out some audits of the home and there are some residents and relative surveys these are not pulled together with for example concerns raised, building and maintenance issues, accident and falls records to give a full picture of the home. This information should be collected together to produce an annual plan for development for the next year. This can then be presented to relatives and residents for their views in how the home can continue to develop. The home keeps a small amount of resident’s money to assist relatives that have management of this. Two residents’ money were looked at. The home had receipts of spending on hairdressing, toiletries and chiropody that was the major part of the spending that residents did. A number of residents needed assistance in purchasing clothes. The manager said that residents in the home appeared to receive items such as clothing and so on when requested from representatives that hold residents’ money. A number of maintenance and inspection records were looked at for fire safety, gas checks and electrical installation reports and these were satisfactory. The home had evidence of a weekly fire alarm test. The home had a drill the previous week when a smoke detector raised the fire alarm in one of the bedrooms. Another smoke detector was set off on the day of the inspection. The inspector was advised that the detectors had been activated by dust. All such detectors need to be freed from dust without delay. The staff acted appropriately at the time. The home stated that they used a video recording about the process of ensuring fire safety in the care home and that occasionally a recognised trainer provides some experience to staff in use of fire extinguishers. The emergency lighting and fire alarm system had been maintained. The home had not yet checked the liability insurance of the hairdresser and must provide evidence that the homes own insurers are willing to cover this. Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 2 3 3 3 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 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 3 2 X X 2 X 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 2 X 3 X X 3 Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? Yes Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 26 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 OP2 Regulation 5(1)(b), 6(a) Requirement The home must advise residents of any changes to the homes contract with them including changes in fees and copies of these letters must be available for inspection. The home must ensure that information of how residents are at risk is in enough detail to minimise the risk effectively. The home must ensure that the care plan contains appropriate details from the personal profiles to guarantee that residents receive the care in the way that they wish. The residents must be consulted regarding the activities being offered in the home before organising a programme of events. (This remained outstanding since 30/11/05.) Records must be maintained of the activities offered and undertaken in the home. (This remain outstanding since 30/11/05) A record of the individual staff time with residents that are unable to join group activities must be recorded. The home must ensure that DS0000017037.V326693.R01.S.doc Timescale for action 28/02/07 2. OP7 13(4)(c) 28/02/07 3. OP7 15(1) 15/03/07 4. OP12 16(2)(n) 28/02/07 5. OP12 12(1)(a) 28/02/07 6. OP14 12(3) 28/02/07 Page 27 Hawthorns, The Version 5.2 7. OP15 12(3), 16(2)(i) 23(2)(b) 23(2)(c) 8. 9. OP19 OP19 10. OP21 13(4)(c) 11. OP24 23(2)(b) (c) residents are enabled to make active choices about their clothing, meals and activities. The home must demonstrate that menus are discussed and changed to meet residents’ wishes. The kitchen area must be refurbished to ensure that all areas are cleanable. The home must ensure that the delivery of hot water to identified bathrooms and wash hand basins is improved upon. Shower chairs and in bath hoists must where appropriate have stoppers to prevent the entrapment of skin. The home must ensure all rooms are checked routinely for signs of wear and tear including decoration, furniture and mattresses and a record of these checks maintained. All of the home’s mattresses must be checked for signs of wear. The lock to the laundry door must be of a type that can be opened from the inside. (Not inspected on this occasion.) The lock to the cellar door must be of a type that can be opened from the inside. The home must ensure that they receive a new, clear, Protection of Vulnerable Adults list check before employing staff. The home must send to the Commission dates for update Moving and Handling training for all staff and the date of the next First Aid training. The home must have in place a quality assurance system based on the views of the residents. (Outstanding since 01/04/06) DS0000017037.V326693.R01.S.doc 28/02/07 31/05/07 28/02/07 28/02/07 28/02/07 12. OP26 13(4)(c) 28/02/07 13. 14. OP26 OP29 13(4)(c) 19 Sch 2 28/02/07 15/02/07 15. OP30 13(5) 28/02/07 16. OP33 24(1) 31/03/07 Hawthorns, The Version 5.2 Page 28 17. 18. OP38 OP38 23(4)(e) 25(2)(e) And That takes account of quality audits and results in an annual report. All smoke detectors must be freed from dust particles to improve their performance. The home must send evidence to the Commission that their public liability insurers are willing to insure the hairdresser that comes to the home. 28/02/07 28/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard OP3 Good Practice Recommendations The home should ensure that letters sent to residents and or their representatives are dated to provide the evidence that they have been assured that the home can meet their needs prior to admission. The home must ensure that medicines that remain in stock at the end of the Medication Administration Record (MAR) must be carried over to the new record. It is recommended that the home set up a record of concerns raised so this can feed into the home’s quality assurance system. It is recommended that the home reissue the complaints procedure for relatives to take away. Staff rotas must show the role staff are undertaking on each shift. 2. 3. OP9 OP16 4. OP27 Hawthorns, The DS0000017037.V326693.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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. 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