Inspection on 16/10/05 for Hawthorns, The

This inspection was carried out on 16th October 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Hawthorns, The 22/12/08

Hawthorns, The 12/01/07

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 Kulwant Ghuman Unannounced Inspection 18th October 2005 12:30 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.V260021.R01.S.doc Version 5.0 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.V260021.R01.S.doc Version 5.0 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.V260021.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd June 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. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was carried out over one day in October 2005 and was the second inspection for 2005/2006. This report should be read in conjunction with the report of the inspection of 22nd June 2005 to get a full overview of all the standards assessed throughout the inspection year. Since the last inspection there has been very little change in the staff working at the home providing a continuity of care for the residents. During the visit a tour some bedrooms and the communal areas of the home was carried out, two resident files as well as other care and health and safety records were sampled. The inspector spent time with the manager of the home and the administrator of the home and spoke with 8 of the residents. What the service does well: What has improved since the last inspection? Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 6 The assessment of residents prior to admission to the home and the care plans following admission had been developed so that the resident could be assured that the home would be able to meet their needs. A new tissue viability assessment had been introduced into the home. Also an ‘individual aims’ sheet had been introduced for the residents. With further development of this document it should become a good tool with which the aims and objectives for the individual residents could be measured. The management of medicines in the home had improved. Two bedrooms and a bathroom had been decorated since the last inspection and new windows had been installed at the side of the home as well as a new gate. The care manager had completed the Registered Managers Award and was awaiting the certificate. What they could do better: The home needed to continue to develop the care planning and risk assessment documentation to ensure that they cross referenced to each other and contained all the required detail to enable care staff to provide the care in the way the resident preferred. Documentation should also be developed to show that the staff have read and understood the care plans and risk assessments. The ‘individual aims’ should be developed to include timescales within which the aims would be achieved. The home needed to ensure that it consulted the residents on either an individual or group basis on issues such as activities, menus and care plans. An activities programme should be developed based on the outcomes of the consultations to ensure residents were enable to undertake activities that suited them. There also needed to be records maintained of activities offered and undertaken and by whom. The evening meals needed to be extended so that there was a variety in the meals available and to include hot meals instead of sandwiches. The manager needed to ensure that staff received a minimum of 6 supervision sessions and a training matrix was in place. Records about the fire training and fire drills needed to be accurate. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 7 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. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 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.V260021.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3,4,5 Assessments of prospective residents were carried out before admission and invited to visit the home before deciding to move in ensuring that both the home and the resident were confident that their needs could be met by the home. EVIDENCE: The files of two residents were sampled. One was of a new admission to the home and the other of a resident who had been living at the home for some time. The home had had carried out an assessment of the resident where they were living prior to admission to the home. The assessment including information provided by other professionals. The resident had been invited to visit the home prior to the admission and a letter was then sent to inform the person that the home was able to meet their needs. There was a delay in admission and a further assessment was carried out before admission to the home. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 10 It was recommended that in order for the residents to maintain control over areas of their lives they managed before being admitted to the home the residents abilities to undertake and maintain responsibility for tasks should be assessed before admission and during the trial period to ensure that dependence on the home was not encouraged, for example, the self administration of medicines, with the appropriate checks in place. No resident had been placed at the home by the local authority since the last inspection therefore the requirement made at the previous inspection has been carried forward to this report. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10 Care plans were improving with more detail to ensure that the needs of residents were being met. The health care needs of residents were being met and the administration of medicines was well managed. EVIDENCE: The care plans were being developed and improvements being made in respect of the detail within them. One of the care plans sampled had only brief details of the resident’s needs as they had only recently been admitted to the home. This care plan needed to be continued to be added to ensure that the documentation evidenced the resident’s needs and how they were to be met by the staff. There needed to be evidence that the resident and/or their representatives were involved in drawing up and reviewing the care plans. The other care plan was for someone who was fairly independent and needed only some assistance. There were tissue viability assessments and some information available regarding the nutritional needs of the residents. A new tissue viability assessment had been introduced into the home so that it correlated with the one used by the district nurses. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 12 There were several risk assessments in place. One of the falls risk assessments did not identify which sling was to be used with the hoist, although this information was available in the care plan. The home undertakes a recorded monthly overview of the residents needs to ensure that significant events and changes in the residents’ needs are identified. There appeared to be good relationships with district nurses and other health care professionals with the dentist, district nurses, chiropodists and GP’s visiting on a regular basis. The GP visited the home on a regular basis to ensure that the residents’ health was monitored with blood pressures etc being checked at least on a yearly basis. The home had also implemented an ‘individual aims’ sheets for the residents. These were a good development but they needed to be broken down into measurable events and needed to have timescales in which they would be achieved and signed by the resident. The home used a monitored dosage system for the administration of medicines. The home undertook some random audit checks and gaps had been identified on the MAR charts. The new MAR charts had been in use in the home for only two days and there were no evident discrepancies in the administration of medicines. On auditing the homely remedies there were some discrepancies for the Senna and Paracetemol tablets. The recording for these needed to be closely monitored and amounts brought into the home recorded. Eye drops needed to be dated on opening. Tubs of cream needed to be dated on opening and it would be better if they could be fitted with pump dispensers to prevent cross infections. Copies of prescriptions were being kept with the MAR charts and all except a new member of staff had undertaken accredited training in the handling of medicines. There was nothing observed during the inspection to indicate that the dignity and privacy of residents was not maintained. There were privacy locks on bathrooms. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Residents were not subjected to any rigid rules and routines but the home needed to develop activities that met the individual needs of the residents. Contact with family and friends was encourage. The evening menu needed to be more varied. EVIDENCE: There did not appear to be any rigid rules and routines in the home. One resident told the inspector they could get up and go to bed when they wanted. Residents were observed to choose whether to have a drink of tea in the lounge or the dining room. Some residents spent a lot of time in their bedrooms, out of choice. Discussions with the manager of the home indicated that were some activities available in the home including hair dressing, videos, television, bingo, quoits and bowls. There were some entertainers who visited the home. Residents were also taken out for a walk around the block however; the inspector could not evidence how often this happened without reading through all the daily recordings or monthly evaluations for all the residents. One of the residents stated that ‘they did not go out on trips like they used to’ whilst another stated that they were happy to stay in the home and sit in the garden when the weather was good. The manager stated that it was better to arrange Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 14 individual activities with the residents and sometimes they occurred on the spur of the moment. This was entirely appropriate however, there needed to be a system for recording what activities had taken place and who had taken part. This issue should form part of their care plan and individual aims and then it could be monitored to determine whether it was being achieved and if not why not. The residents needed to be consulted either on an individual basis or on a group basis before arranging activities. Residents were able to have visitors at all reasonable times. There was a visitor in the home at the time of the inspection and it was one of the residents birthday. Records of what the residents ate was maintained and examination of this record for one resident over the past few weeks showed that although there was some variety in the main meal of the day the evening meal was usually sandwiches of some type. When asked about whether the residents got bored with sandwiches one resident said “wouldn’t you get bored with sandwiches”? The home needed to ensure that there was variety in the evening meal and include some hot items on the menu, particularly as the seasons and weather were changing. The kitchen was not inspected in any depth at this inspection but was seen to be clean and tidy. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Residents were safeguarded through the homes complaint and adult protection procedures. EVIDENCE: Discussion with the residents showed that they were happy with the service and would not hesitate to raise any concerns with the manager. There had been no complaints raised at the home none had been lodged with the CSCI regarding the home. The complaints procedure was not examined at this inspection but the inspector was informed that there was one on display in the home. There had been no issues of adult protection raised regarding the home that the inspector was aware of. A requirement was made at a previous inspection that all staff needed to undertake adult protection training. The inspector was unable to audit this, as there was no training matrix in place. This requirement has been brought forward to this report. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,24,25,26 The residents lived in a safe, well-maintained environment with facilities that met their needs. EVIDENCE: The home continued to provide care in a homely and comfortable environment. There was an ongoing programme of decoration in the home. Two bedrooms and a bathroom had been decorated since the last inspection and new windows had been installed at the side of the home as well as a new gate. The inspector was informed that the carpet in the communal areas on the ground floor was being deep cleaned on a regular basis. This carpet will need to be replaced within the next year. The garden area was accessible to residents via a steep ramp or via a side exit. There was communal space available for residents in the form of one lounge, and a smaller sitting area between the lounge and the conservatory that was used by residents as a smoking area. The area between the lounge and Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 17 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 carpet in the dining room was rucking and posed a potential tripping hazard. During the inspection it was noted that three zimmer frames were stored away from the residents to whom they belonged. One of them had an instruction from the hospital that it should not be placed near the resident as they would get up and walk and during the inspection the resident was seen to stand up on several occasions without the frame and staff persuaded her to sit down. One of the other frames had been moved away from the resident, as it was a possible tripping hazard for residents. The fact that the removal of zimmer frames could be seen as a form of restraint was discussed with the manager who was in agreement and would endeavour to address the situation as far as possible because the residents had chosen where they sat and did not wish to move. One member of staff was seen to trip over a resident’s walking stick and narrowly missed falling and hurting herself. This could also be a potential risk to residents and the home needed to look at the seating arrangements to determine whether anything could be done to minimise this risk. Staff must ensure that the zimmer frames are made available to residents when they want. The inspector observed staff asking a resident to sit down several times but made no attempt to find out why she was getting up and where she wanted to go. Bedrooms seen were found to be clean and comfortable and personalised with the resident’s belongings. There was an odour control issue in one of the bedrooms. Attempts had been made to address this issue but it was likely that the flooring needed to be replaced. The manager and owners had already discussed this. The agreement of the residents, where possible, and their representatives needed to be sought before the carpeting was replaced with hard flooring. Lighting throughout the home was domestic in appearance except in the dining room where there was fluorescent lighting. The home did not intend to replace this lighting. There were adequate numbers of toilets close to the lounges and dining rooms. There was an assisted bathing facility on all floors. The bathroom where the connecting door to one of the bedrooms had been closed off was not inspected as it was in use at the time of the tour of the building. Many of the bedrooms had en-suite facilities consisting of toilet and wash hand basin and met the needs of the residents with respect to furniture. There were adaptations to the home such as ramped access, stair lifts, emergency call system, grab rails and mobile hoists. One resident told the inspector that she did not know where the emergency call point was in her Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 18 room and was unable to call for assistance. The home needed to place the emergency call point so that it was visible to her when in bed. The laundry was narrow in structure but well organised. During the tour of the building the door to the laundry had been bolted locking a member of staff in. The home needed to ensure the lock on this door could be opened from the inside to prevent anyone being locked in there. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 19 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,30 There were adequate numbers of staff on duty to meet the needs of the residents. EVIDENCE: There were two care staff on duty during the morning in addition to the manager. In the evening there were 3 staff on duty until 8pm when this dropped to 2 staff. There were 2 staff on duty at night. There were staff that were employed specifically to undertake care, cooking and cleaning. The staff had achieved a target of 50 of the care staff being trained to NVQ Level 2 or above. The inspector was told that all staff had undertaken mandatory training and that some had taken additional training in stoma care, falls awareness, complimentary therapy and sight loss. The home needed to put in place a training matrix that would identify the training taken by individual staff and what training was required. There were good relations observed between the staff and the residents however the staff needed to be vigilant in the increased needs of residents with dementia, for example, a resident who continually tried to get up and out of her seat was asked by staff to sit down, no effort was made to determine where she wanted to go and why. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 20 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,36,38 Management of the home ensured the health and safety of the residents. EVIDENCE: The manager told the inspector that she had completed the Registered Managers Award and that the certificate was awaited. She had been managing the home for several years and ensuring that it was developing in line with the National Minimum Standards. Management of the home could be further improved by developing the involvement and consultations with the residents in particular with respect to care plans, activities and menus and ensuring that their opinions are incorporated into the home’s development plan. The home carried out some surveys and questionnaires but they were not dated and it was not evident how this information had been used to improve the service provided by the Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 21 home. The home was required to have a quality assurance system in place that was based on the views of the residents and their representatives. The supervision records of two staff were sampled. Both had been supervised three times during the past twelve months. The records of the supervision were very basic and supervision sessions needed to include topics such as development of the individual and the home, discussions of residents needs, issues of practice and policy and procedures. The records sampled during this inspection indicated that the home was being managed in a way that promoted the health and safety of residents. The records within the home were well organised and easily accessed. The weekly fire alarm testing and monthly emergency lighting tests were up to date. Training for staff in fire procedures was being carried out however, it was determined that staff were not observing the video although the records indicated that they did. The actual content of the training needed to be recorded. The fire drills were carried out at the same time as the fire training and this could be one individual or a group of individuals. The fire drills needed to be carried out when the staff were not aware that a drill was to be carried out and the actions of the staff team monitored. The staff undertaking the drill and the time taken to complete the drill needed to be recorded. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 2 2 3 2 X 3 3 3 STAFFING Standard No Score 27 3 28 2 29 X 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X X 2 X 2 Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP3 Regulation 4(1)(a) Requirement The registered person must ensure that they obtain an assessment carried out by the social worker before being admitted to the home. (Previous timescale of 6.10.04 not met. Compliance with the timescale of 01/09/05 not assessed as no resident had been placed through the social workers. ) The care plans must continue to be developed to include all the required detail and to show that the resident or their representatives have been involved in drawing them up. The eye drops and creams must be dated on opening. There must be a clear audit trail for the homely remedies. The residents must be consulted regarding the activities being offered in the home before organising a programme of events. Records must be maintained of the activities offered and undertaken in the home. Variety must be introduced into DS0000017037.V260021.R01.S.doc Timescale for action 01/12/05 2. OP7 15(1) 01/12/05 3. 4. 5. OP9 OP9 OP12 13(2) 13(2) 16(2)(n) 18/10/05 30/10/05 30/11/05 6. 7. OP12 OP15 12(1)(a) 16(2)(i) 30/11/05 01/11/05 Page 24 Hawthorns, The Version 5.0 8. OP18 13(6) 9. 10. OP20 OP22 13(4)(c) 13(6) 11. 12. OP22 OP26 23(2) 13(3) 13. 14. OP26 OP26 13(4)(c) 13(3) 15. OP29 19 Sch 2 16. 17. OP30 OP30 18(1)(a) 18(1)(c) the evening meal. The registered person must ensure that all staff receive training regarding the adult protection procedures and what happens in the event that an allegation is made. (Previous timescales given 1.4.05 and 01/10/05. Compliance not assessed at this inspection.) The carpet in the dining room must be stretched to remove the ripples in it. The manager must ensure that mobility aids are readily available to residents and where they have to be removed for reasons of health and safety that they are made available to residents when they want them. The emergency call point must be accessible to the resident identified. The bath seats must be kept clean. (Previous timescale given 14/08/05. Compliance not checked at this inspection.) The lock to the laundry door must be of a type that can be opened from the inside. Agreement must be reached with the residents’ family on how to manage the odour control issue in the bedroom. The registered person must ensure that all the documents required by Schedule 2 of the Care Homes Regulations are in place before staff commence employment. (Previous timescale of 06/10/04 not met. Compliance with timescale of 14/08/05 not assessed at this inspection.) A training matrix must be in place to show when training was undertaken. Records of induction training DS0000017037.V260021.R01.S.doc 01/04/06 15/11/05 01/11/05 15/11/05 14/11/05 14/11/05 01/12/05 14/12/05 14/12/05 14/12/05 Page 25 Hawthorns, The Version 5.0 (i) 18. 19. OP33 OP38 24(1) 13(4)(c) 20. 21. OP38 OP38 23(4)(d) 23(4)(e) must be available for inspection. (Previous timescale given 14/08/05. Compliance not checked at this inspection.) The home must have in place a quality assurance system based on the views of the residents. The home must ensure that the hairdresser had adequate liability insurance. (Previous timescale given 14/08/05. Compliance not checked at this inspection. The records of fire training must include details of the actual training undertaken. Fire drills must include details of the staff taking part and the time taken. 01/04/06 01/12/05 01/12/05 01/12/05 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. 2. Refer to Standard OP3 OP9 Good Practice Recommendations The home should ensure that an assessment of the resident’s abilities to retain responsibility for tasks is assessed and recorded. Creams should be dated on opening and fitted with pump dispensers. Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Birmingham Office 1st Floor Ladywood House 45-46 Stephenson Street Birmingham B2 4UZ 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 Hawthorns, The DS0000017037.V260021.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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