Inspection on 19/10/05 for Hawthorns, The

This inspection was carried out on 19th 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 32 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hawthorns, The 23/05/07

Hawthorns, The 26/06/06

Hawthorns, The 11/05/05

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 Hawthorns, The Walkmill Drive Wychbold Worcestershire WR9 7PB Lead Inspector N Andrews Unannounced Inspection 19th October 2005 08:45 Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 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 DS0000035065.V260761.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 Adults 18-65. 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 DS0000035065.V260761.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hawthorns, The Address Walkmill Drive Wychbold Worcestershire WR9 7PB 01527 861755 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) Yunicorn Limited Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. LD/MD for 3 both sexes LD/PD for 3 both sexes Date of last inspection 11th May 2005 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. There is limited parking at the front of the premises and an enclosed garden at the rear. The property 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 of the service users has an en suite bathroom. The other two service users 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. The service users may also present challenging behaviour. 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. Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place during the course of one day. The primary purpose of the inspection was to assess the service users’ safety and wellbeing and to ensure that they were receiving an appropriate standard of care. The newly appointed acting manager had been in post for only three days and did not have a copy of the most recent inspection report dated 11 May 2005. Therefore, the majority of time was spent with the acting manager discussing the needs of the service users, the recent difficulties that the home had experienced, the improvements that were being made and the work that still needed to be carried out in order to ensure that the home meets all of the National Minimum Standards (NMS). The home’s response to the requirements and recommendations that were made as a result of previous inspections was not assessed. Therefore, all of the outstanding requirements and recommendations arising from previous inspections of the home are repeated in this report with the same timescales for implementation. The requirements and recommendations should be read more appropriately in the context of the previous inspection report. During this inspection eight of the National Minimum Standards were fully assessed in the company of the acting manager and one of the service users and with the help of a member of staff. A brief discussion was also held with the registered provider. What the service does well: What has improved since the last inspection? What they could do better: The extent to which the requirements and recommendations arising from previous inspections of the home had been implemented had still to be assessed. This, together with other improvements that may have been made since the previous inspection, will be fully assessed during the next full inspection of the home. In the meantime, the acting manager will have the Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 6 opportunity to settle into her new role, to familiarise herself with the needs of the service users and to prioritise the work that needs to be done. 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 DS0000035065.V260761.R01.S.doc Version 5.0 Page 7 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 Outcomes Statutory Requirements Identified During the Inspection Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 8 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 the following 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. EVIDENCE: N/A Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 9 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 the following standard(s): 7 The service users were given appropriate help and support to enable them to make decisions about their lives and the issues that affected the care that they received. EVIDENCE: It was confirmed that the service users’ right to make decisions was upheld by all the staff. It was also stated that the service users were encouraged, as much as possible, to make choices e.g. in regard to the food they ate and the clothes they wore. The staff helped the service users in this process by providing explanations and pictures/symbols. The service users’ relatives were also consulted. The newly appointed acting manager acknowledged that she was in the early stages of making relationships with the service users and their families. The acting manager stated that she intended to hold a meeting with the service users’ relatives in order to begin the process of developing a positive relationship with them. The relatives of two of the service users were very involved in their care. The relatives of one of the service users had very limited contact with the home. It was stated that none of the service users required the support of an advocate at the present time. None of the service users were able to manage their own finances. The acting manager said that she hoped to enable the service users to carry small amounts of money with them, if possible, in order to encourage their independence. It was confirmed Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 10 that none of the service users ever went out of the home without an escort and that they were always appropriately supervised e.g. at meal times, when bathing and undertaking personal care tasks and in the kitchen. A requirement was made as a result of the previous inspection regarding the financial records held on behalf of the service users. The acting manager gave an assurance that the records maintained by the home were correct and up to date. However, it was noted that the key to the cabinet in which the records of the service users’ finances were kept was not available. Therefore, it was not possible to assess the home’s response to the requirement. The acting manager was aware that such records must always be available for inspection. The assurance that was given that, in future, access to the cabinet would always be provided was accepted. Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 11 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 the following standard(s): 14, 15 and 17 The service users engaged in appropriate activities and they were supported to maintain their links with their families. The food provided was of a satisfactory standard and the home catered for the service users dietary needs and preferences. EVIDENCE: It was confirmed that the service users were provided with a range of appropriate social and leisure activities. The activities that had been undertaken during the summer had included picnics, a visit to Weston-SuperMare, pub lunches, a visit to a theme park and meals out. The home had its own vehicle in the form of a ‘people carrier’. This was regarded by the staff as an essential means of transport to enable the home to access the necessary range of leisure facilities needed by the service users. Two of the service users enjoyed regular home visits to their families every four to six weeks. The relatives of the same service users also maintained regular and supportive contact with the home through visits and telephone calls. Various games and activities were provided ‘in-house’. One of the service users enjoyed baking. Another service user enjoyed listening to music, watching television and looking at magazines. A Christmas party is planned. During the summer one of the service users went to Brean for a four-day caravan holiday. Another Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 12 service user visited the Isle of White for four days and another service user went to Butlins at Minehead for four days. One of the service users also went on holiday with members of his family. The home’s response to the recommendation that was made as a result of the previous inspection regarding the service users’ holidays was not fully assessed and, therefore, still stands. There was evidence to show that the staff support the service users to maintain links with their families. The relatives of the service users were welcomed and their involvement in the home was encouraged. The service users did not attend any day centres or college courses. Their contact with other people who do not share their disabilities was limited. However, it was confirmed that the service users were settled and had not shown any signs of distress as a result of the disruption caused by the recent staff changes. The relationships that the service users had with the staff were described as positive. It was confirmed that none of the service users had any known allergies and that they were neither overweight nor underweight. It was also confirmed that the service users were weighed at least once a month and that a record of their weight was maintained. The whole-milk intake of one service user had been increased. None of the service users had any other special dietary needs for any religious, cultural or healthcare reasons. It was stated that the food preferences of all the service users were known by the staff and were recorded. The food for one service user was always cut into small pieces partly to avoid the risk of choking. It was confirmed that a risk assessment had been carried out and recorded in regard to the service user’s risk of choking. It was also confirmed that a member of staff was always present when the service users ate their meals. Breakfast was served between 7:45 and 10:00 am. Lunch was usually served between 12:30 and 1:30 pm. The teatime meal was served between 5:30 and 6:00 pm and supper, which usually consisted of drinks and biscuits, was served at approximately 8:00 pm. Drinks and snacks were available throughout the day. The service users were encouraged to help prepare meals within their capabilities. The service users usually ate breakfast in their own bedrooms. The staff encouraged the service users to eat the evening meal together in the dining room. None of the service users had any eating or drinking disorders. Two service users required the use of plates with a lip that enabled them to feed themselves more easily. Two of the service users found it easier to eat their meals using a spoon. None of the service users required the assistance of the staff to eat. However, one of the service users needed to be encouraged to eat. A satisfactory record of the food provided was being maintained. The space on the form that was used to record the food needed to be enlarged in order to enable the staff to maintain clearer details. The food provided was varied and nutritious. Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 13 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 the following standard(s): 18 and 19 The service users received appropriate personal support and suitable arrangements were in place to ensure that their healthcare needs were met. EVIDENCE: Two of the service users needed to be guided. One of the service users had poor balance and another service user needed to be encouraged to walk. The service users required staff supervision or assistance in regard to personal care tasks. It was confirmed that staff help with personal care was always provided discreetly and in private. It was stated that one of the service users needed a new shaver and that this would be provided. The daily routines e.g. times for getting up/going to bed, baths and meals etc, were flexible. The service users were encouraged to make choices in regard to the clothes they wore. The service users visited the local hairdresser. The home employed both male and female staff as well as staff from the ethnic minority community. This provided an element of choice for the service users regarding who worked with them. One service user required the use of a wheelchair and a hoist. It was stated that another service user had a hoist that needed to be changed. A new hoist had been recommended by the occupational therapist. The acting manager said that she would follow up the recommendation. Handrails were provided in appropriate places. It was stated that the physiotherapist visited in March 2005. A key worker system was in operation. The staff group had undergone several changes in the recent past. The acting manager hoped that the staffing arrangements would become more settled. The acting manager Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 14 also recognised the importance of staff training and the need to provide a consistent approach to care. Information about the healthcare needs of the service users had been obtained from outside professionals. The staff offered the service users appropriate assistance in regard to healthcare issues. The two female service users attended a well women’s clinic annually. It was confirmed that a record of the visits and the outcome were maintained in the service users’ files. The three service users were registered with local GPs. The service users’ health was monitored by the GPs. The service users’ hearing was checked by the GP. None of the service users were able to self medicate. One service user had epilepsy. This was managed by medication and a chart that recorded seizures was maintained. It was stated that a risk assessment had been carried out and recorded in regard to the seizures. However, the risk assessment was not available for inspection. A chiropodist visited the home every eight weeks. The service users visited Bromsgrove Hospital annually for dental checks. The service users’ eyesight was also checked annually. It was stated that the staff had no concerns about the service users’ general health. Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 15 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 the following 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. EVIDENCE: N/A Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 16 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 the following 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. EVIDENCE: N/A Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 17 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 and 34 There was evidence to show that the staffing arrangements had stabilised since the previous inspection. However, the staff recruitment procedures were still in need of improvement. EVIDENCE: The home was still without a registered manager. However, the newly appointed acting manager had commenced working at the home on 17 October 2005. She was employed for 40 hours per week. In addition to the acting manager, the home employed two senior support workers and seven support workers for a total of 322 hours per week. However, no staff were employed specifically to undertake catering, laundry or domestic duties. The home did not employ any staff to provide administrative support. It was stated that there were no staff vacancies and that agency staff were not used. The home operated daytime shifts from 7:30 am to 3:00 pm and 2:00 pm to 9:00 pm. Normally, only two members of staff were on duty from 6:00 pm to 9:00 pm and only one member of staff was on sleeping-in duty at night. There had been a high turnover of staff within recent months. The former acting manager and three support workers had left the home. None of the current staff were below the age of 21 years. Copies of the staff rota for the two weeks prior to the inspection were made available for inspection. However, the details recorded in the staff rotas were not sufficiently clear to enable an accurate assessment of the adequacy of the staffing cover to be made. It was also not possible from the details recorded in the staff rota to fully assess the home’s response to the requirements and recommendation made in regard to Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 18 Standard 33 as a result of previous inspections. The acting manager is requested to ensure that the details recorded in the staff rota of the hours that are worked by all the staff are clear and accurate. Evidence was provided to show that four staff meetings had been held since 3 February 2005. In addition, a staff meeting was held on the day of the inspection. The contents of the files in respect of four members of staff were inspected. One of the staff files contained only one written reference. The same file did not contain an application form, a photograph or any proof of identity. The information that was available in respect of other staff that had been appointed to the home more recently had not yet been constructed into files and, therefore, the files were not available for inspection. It was stated that the CRB checks that had been carried out on the staff were held in a separate file. The file was not available for inspection. The requirement that was made in regard to this Standard as a result of the previous inspection had not been implemented and still stands. This Standard will be fully assessed during the next inspection of the home. Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 19 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following 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. EVIDENCE: N/A Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 20 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 X X X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 2 X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 2 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X 2 1 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hawthorns, The Score 3 1 X X Standard No 37 38 39 40 41 42 43 Score X X X X X X X DS0000035065.V260761.R01.S.doc Version 5.0 Page 21 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 YA1 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 31/01/05 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 31/01/05 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 the previous report. (Previous timescale of 31/01/05 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 DS0000035065.V260761.R01.S.doc Timescale for action 30/06/05 2 YA1 5 30/06/05 3 YA2 14 30/06/05 4 YA6 15 30/06/05 Hawthorns, The Version 5.0 Page 22 5 YA7 17 6 YA9 12,17 7 YA16 12,17 8 YA20 18 9 YA20 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 31/01/05 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 31/01/05 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 31/12/04 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 outcomes and any action taken to minimise the risks recorded in their individual care plans and reviewed. (Previous timescale of 31/12/04 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 DS0000035065.V260761.R01.S.doc 30/06/05 30/06/05 30/06/05 30/06/05 30/06/05 Page 23 Hawthorns, The Version 5.0 10 YA22 22 11 YA22 22 12 YA23 12,13 13 YA23 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 home’s policy on medicines handling and records. (Previous timescale of 31/03/05 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 31/12/04 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 31/12/04 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 31/01/05 not met). The home’s policy and procedure on whistle blowing must be reviewed and revised in accordance with the Public DS0000035065.V260761.R01.S.doc 30/06/05 30/06/05 30/06/05 30/06/05 Hawthorns, The Version 5.0 Page 24 14 YA24 23 15 YA26 16 16 YA28 13 17 YA28 13 18 YA29 13,23 19 YA32 18 20 YA33 17 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 31/01/05 not met). All of the outstanding fire safety precautions as specified in the Fire Safety Officer’s 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 31/12/04 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 31/03/05 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 31/03/05 not met). A suitable bath hoist and grab rail as recommended by the occupational therapist must be provided in the bathroom on the first floor. All of the staff must undertake training in the protection of vulnerable adults from abuse. (Previous timescale of 31/03/05 not met). The duty rota must show which members of staff are on duty at DS0000035065.V260761.R01.S.doc 30/06/05 30/06/05 30/06/05 30/06/05 30/06/05 30/06/05 30/06/05 Hawthorns, The Version 5.0 Page 25 21 YA33 17 22 YA33 18 23 YA34 19 24 YA35 12,18 25 YA35 18 26 36 18 27 YA39 24 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 home’s 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 31/01/05 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 31/03/05 not met). 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 31/03/05 not met). 30/06/05 30/06/05 30/06/05 30/06/05 30/06/05 30/06/05 30/06/05 Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 26 28 YA41 7,9,17,19 29 YA42 26 30 YA42 13,18 31 YA42 13,18 32 YA42 13,18 33 YA42 13 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 31/03/05 not met). 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. 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. All staff must receive updated training in moving and handling, food hygiene, epilepsy awareness, the administration of rectal diazepam and fire safety. All staff must receive equal opportunities training, including disability equality training provided by disabled trainers; and race equality and antiracism training. An opening restrictor must be fitted to the window in one of the service users’ bedrooms on the first floor. 30/06/05 30/06/05 31/07/05 31/07/05 30/09/05 18/05/05 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 Refer to Standard YA4 Good Practice Recommendations Details of the home’s practice regarding pre-admission DS0000035065.V260761.R01.S.doc Version 5.0 Page 27 Hawthorns, The 2 YA5 3 YA5 4 YA8 5 6 YA10 YA14 7 YA16 8 YA23 9 YA24 10 YA32 11 12 13 14 YA33 YA34 YA35 YA36 visits, a minimum three-month settling-in period for new service users and the home’s ‘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 the previous 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 home’s 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 home’s 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 home’s 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 has been completed or addressed. Arrangements should be made for staff to receive training 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 home’s 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 DS0000035065.V260761.R01.S.doc Version 5.0 Page 28 Hawthorns, The 15 16 17 18 19 YA36 YA37 YA38 YA38 YA38 20 21 YA39 YA40 manager to review performance against job descriptions and agree career development plans. All of the staff should be issued with a copy of the home’s written grievance and disciplinary procedures. The registered manager’s 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 home’s 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 home’s policies and procedures. Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 29 Commission for Social Care Inspection Worcester Local Office 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 Hawthorns, The DS0000035065.V260761.R01.S.doc Version 5.0 Page 30 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!