Inspection on 23/05/07 for Hawthorns, The

This inspection was carried out on 23rd May 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Hawthorns, The 26/06/06

Hawthorns, The 19/10/05

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 Dianne Thompson Key Unannounced Inspection 23rd May 2007 10:00 Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 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.V334587.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 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.V334587.R01.S.doc Version 5.2 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 Loraine Summers Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home may accommodate people who have associated physical disabilities or mental disorders. Date of last inspection 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 four adults with learning disabilities who may also have a mental disorder or a physical disability. The people who use the service are accommodated on the ground and first floor of the building. The communal space includes a combined lounge and dining area, a Snozelen and a conservatory. The people who use the service have needs that fall within the Autistic Spectrum Disorder range of disability, and may also present challenging behaviour. The current fee for the service is £338.00 per week. Charges which are additional to the fee include: • • • • Personal toiletries, clothing and electrical items Holidays Major extra outings Hairdressing Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The main purpose of this inspection was to see what the service at The Hawthorns was like for the people who live there. Records for people who use the service were checked, and a tour of the building was also carried out. A random inspection visit has been made since the last inspection, and information obtained during that visit is included in this report. Other information gathered by the Commission for Social Care Inspection (CSCI) is included in this report. Surveys and Relatives comment cards were sent out. Time was spent with people who use the service, the registered manager, the deputy manager and staff on duty. What the service does well: The home gives clear information to people who use the service about the home. Before someone new moves into the home staff check that they will be able to give them the care they need. The home looks after people well and writes down what help everyone needs. People who use the service are given help and support to do the activities they choose. Families and friends are welcome to visit the home. People who use the service can choose what they like to eat from the healthy menu at the home. People are supported with their medical appointments and their health care. All staff are trained to give medication safely. People who use the service can talk to staff about any problems they may have. Staff are trained and know what to do if there are any problems. The Hawthorns is homely, clean and tidy. People who use the service can decorate their rooms in the way they like. Staff are being trained. The home checks staff before they start working in the home. Yunicorn checks the home to make sure that everything is being done properly. They check to make sure the home is a safe place to live and work in. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 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.V334587.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People are given information about the services offered at the home to help them make an informed choice about whether they would like to live at The Hawthorns and whether the home will meet their needs. EVIDENCE: The Statement of Purpose and Service User Guide provides information about the home to help people decide if they wish to live at The Hawthorns. The Statement of Purpose has recently been updated to reflect the change in the home’s registration to accommodate a fourth bedroom. The registered manager is currently reviewing and updating all policies and procedures to accommodate the changes to the home’s registration with CSCI. Copies of the information are available to all, including visitors to the home. Information is available in alternative formats to make sure people can understand it. There is evidence that full assessments have been completed for everyone who uses the service. The home has an admissions policy and procedure in place and the home will make sure they are followed for future admissions to the home. The assessment process aims to make sure that the home will receive full Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 9 information about people, their background, their needs, their likes and dislikes when they are referred for a placement. Introductory visits and stays will be arranged at the home prior to admission. The registered manager said that everyone will be given a copy of relevant information prior to moving into the home, and offered in preferred formats, such as symbols, pictures, and large print. The home has one vacancy at present. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Care plans provide staff with detailed information about individual’s assessed needs. They include risk assessments to show how risks are to be reduced and how to promote independence. People who use the service are supported to make choices and decisions in their daily lives and routines. EVIDENCE: The care plans for people who use the service now includes all aspects of their care in accordance with Standards 6 and 2.3, and meets the requirement of the previous inspection. The care plans now provide the details and information that staff need to make sure that all care is provided in a preferred and consistent way. People’s likes and dislikes are included. A person centred care plan (PCP) approach is to be developed within the home. This approach will show how people who use the service are appropriately involved in planning and reviewing their own care. People will be supported to express their wishes and goals. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 11 Files for three people who use the service were examined. Case tracking provides a view of how the home responds to the diversity of needs and how this is being managed and supported. This is particularly evident where health needs and disability requires greater input and support from all staff within the home. Relevant information and monitoring is provided in individual files to make sure all staff have the necessary information to provide quality care. Each person is allocated a key worker to oversee his or her care. Each key worker builds a closer relationship so they gain more understanding and knowledge of individual needs, goals and wishes. Plans are reviewed regularly or as any changes in need occur. Staff said they are fully aware of the plans and use them to guide their practice. The home completes risk assessments to promote safety and independence for people who use the service. Plans provide information about the methods of communication that people who use the service understand. These plans make sure all staff are aware to promote consistency. Family surveys confirmed that care given is what they expected or agreed with the home. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13, 15, 16, 17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People receive help and encouragement to lead active and interesting lives and are supported to access facilities within the community. People are also supported to maintain links with their families and to develop friendships. The home offers a well-balanced menu and promotes healthy eating for the welfare of people who use the service. EVIDENCE: Time was spent with three people who were at home at the time of the inspection visit. Everyone had been out for a picnic lunch by the canal locks in Droitwich. The home provides a range of activities for people who use the service, both in-house and within the local community. All activities are organised to take into account individual needs and preferences, making sure that everyone has Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 13 the opportunity to take part. The manager and staff said that opportunities are discussed regularly with people who use the service. Activity equipment and records are stored in the cupboard downstairs, making information easily accessible for everyone while maintaining confidentiality. Records show that current external activities include shopping, cinema, pub, going out in the car, swimming at the Otters Club, holidays, bowling, and going to a local disco. A recent trip to London included riding on the London Eye and visiting Madame Tussauds. Staff said this trip had been very successful and included train travel to and from London. Holidays are being planned with people who live in the home. Some of the ideas being explored include a trip to Disneyworld in Paris. One person who uses the service indicated they would like to go to the seaside. Activities within the home include involvement in household tasks, watching movies, reading magazines, gardening, listening to music, Snoezelen, and doing jigsaw puzzles. One person who uses the service proudly showed the display of certificates on their bedroom wall for training courses that they have completed. These certificates include training for infection control, challenging behaviour, and Health and Safety. The manager said that these courses were completed together with the staff team. Evidence is available to show that regular contact with friends and family is supported. The home provides well-balanced, varied meals for people who use the service. Menus are planned during meetings when people who use the service make their choices for the coming week. Alternative options are available to those chosen. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal and healthcare needs are identified in care plans. The plans provide information and promote consistency of care and support in the way people prefer. The home has a medication policy and procedure, which is followed to make sure that all medication is administered and stored safely for the protection of everyone who uses the service and staff. EVIDENCE: Individual care records and plans provide information about physical and mental health and the support needed from staff to maintain good hygiene and health. The care plans sampled contain information about preferred personal care routines. Staff said they are able to communicate with people who use the service verbally and, in certain cases, with the additional use of signs and objects of reference. Some people who were at home at the time of the visit were unable Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 15 to communicate, but they appeared to be comfortable, fully involved and at home in their environment. Records of all physical checks are completed where people have particular health related issues such as weight and fluid intake. In this way the home is able to closely monitor and respond to changes or obtain appropriate medical input whenever necessary. People who use the service and the home are supported by medical services, which include GP’s, speech and language therapists, dentist, chiropodist, and community learning disability team. The community nurse has issued health action plans, and staff will do the training to know how to use these. Survey responses from medical professionals confirmed that the home meets the needs of people who live there and that they are satisfied with the overall care provided. The manager shared a concern about a situation that occurred earlier this year where professional support was needed and could not be obtained. The need for a protocol for future support was discussed. The manager is advised to develop a network of support and arrange meetings so this can be established before it is likely to be needed. The home has a medication policy and procedure in place. The registered manager confirmed that the organisations policies and procedures would be followed should any medication error occur. Additionally these would be reported to the CSCI. Medication administration records were seen and appropriate recording is evident. A list of specimen signatures should be held on the medication administration file for all staff that administer medicines. Medicines are suitably and safely stored. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People who use the service are protected by easy to understand information about how to complain, with appropriate information for staff provided. Staff support people to express their views and any concerns they may have. EVIDENCE: The Hawthorns has a suitable complaints policy and procedure in place. The complaints procedure is available in alternative formats where appropriate. There have been no complaints to the home and no complaints have been made to the CSCI since the previous inspection. There are suitable policies and procedures in place to support staff in keeping people who use the service safe. Staff complete training in relation to abuse and protection during their induction and through specific training courses. The manager discusses issues with staff about the protection of vulnerable adults and confidentiality within the workplace. The manager said she describes scenarios and encourages staff to talk through their responses. Sometimes language may be a barrier to clear understanding where English is not their first language, but other staff will assist to ensure that an understanding is reached. Staff on duty at the time of the inspection visit confirmed this. The home has relevant financial policies and procedures in place to make sure that money is kept safe for each person. The people who use the service all have their own post office accounts. One person is able to manage their own Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 17 account but other people are supported with their accounts. Records were seen which show that the registered provider signs the financial records for people who use the service every time they are audited to confirm that they are being maintained correctly. This meets the requirement of the previous inspection. During the inspection visit staff were observed engaging with people who use the service in a supportive and respectful way. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. The Hawthorns provides accommodation that meets the needs of people who use the service, and offers a spacious and comfortable home. The home is kept clean which ensures that good hygiene and infection control is maintained. EVIDENCE: A tour of the home was completed. The Hawthorns is a house with a large lounge and dining area, a smaller lounge, four bedrooms, three bathrooms, three toilets, laundry, and fully fitted kitchen. The kitchen has a table where people can sit and eat if they prefer, and participate in kitchen tasks such as meal preparation. The small lounge is used as a sensory room. People who use the service were seen to enjoy using this room during the inspection visit. There is a small, fully enclosed garden. The home has been extensively improved since the previous inspection. New windows and doors have been replaced throughout which has improved the appearance of the home. The large window has been removed in the ground floor bedroom and replaced with Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 19 a window and door. The person who uses this room now has their own front door and this makes access to the home much easier. The ground floor room has an ensuite with a hoist over the bath. New baths and showers have been installed, and toilets have been replaced. The area of wall in the ground floor toilet that was affected by damp has been repaired, and meets the requirement of the previous inspection. New flooring has been fitted to the kitchen, the conservatory and the bathrooms. Quotes are being obtained for new carpets for the communal areas of the home. The laundry room has been redecorated and a new door has been fitted. An emergency call system is in place. This meets the requirements of the previous inspection. Communal areas of the home have been redecorated since the previous inspection. The decoration has been very nicely done. There is a relaxed and homely atmosphere to the home. The rooms of people who use the service are personalised and clearly show their interests and their independence. Everyone has their own notice board that clearly shows their daily routines and the fire procedures to be followed in the event of an emergency. All rooms are clean, tidy and well presented. There are plans for the bedrooms to be painted. Evidence was seen where people are being supported to choose colour schemes for their rooms. Policies and procedures for infection control are in place and staff are provided with disposable gloves and aprons. Communal bathrooms have paper towels and liquid soap available. All cleaning materials are stored in locked cupboards in the laundry room. Staff were seen wearing appropriate protective wear for the task being completed. The maintenance book now includes all the items that are due for maintenance and renewal for the coming year and the date when the work or item has been completed or addressed. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34, 35, 36 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Staffing levels are being maintained and the staff team understand their responsibilities. Staff are well supported and work together to provide people who use the service with consistent and good quality care. Staff receive relevant training to help them meet the needs of people who use the service. The home’s recruitment policy and practices make sure that suitable staff are employed. All necessary checks are made to ensure the safety of everyone living at The Hawthorns. EVIDENCE: The Hawthorns has a committed and stable staff team. The staffing levels at the home are sufficient at the moment, but may need to increase when the current vacancy is filled. There are two trained nurses within the staff team and three staff with NVQ level 2 or above. The home organises regular staff training. Staff complete mandatory training such as health and safety, fire safety, first aid, food hygiene, moving and handling, infection control and vulnerable adults. Staff said that the training Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 21 has been good. The staff training matrix provides details of all training completed and planned for the coming year. This meets the requirement of the previous inspection. Staff training planned for the coming year include updates for First Aid, Vulnerable Adults, health and Safety, fire safety, epilepsy and autistic spectrum disorder. All staff are trained to administer medication. This meets the requirements of the previous inspection. All staff have now completed an annual appraisal with their line manager to review performance against job descriptions and agree career development plans. The registered manager also encourages staff to complete questionnaires to identify their learning needs and how to improve and develop the service. Evidence was seen to confirm this. Staff are learning how to complete risk assessments. The registered manager provided evidence to show where staff have completed assessments for the grounds and the use of equipment in the kitchen. The manager checks these before they are implemented. The manager said she is empowering staff through delegation and areas of responsibility to develop their learning, knowledge and skills. All newly employed staff complete an Induction Course. The Induction process also includes new staff being supported by senior staff to familiarise themselves with the home, people who use the service and safety matters. A new member of staff confirmed that this procedure was being followed. The home’s recruitment policy and procedures ensure that everyone completes an appropriate application form and that required references are obtained including one from their most recent employer. Appropriate criminal records and other checks are undertaken before their appointment is confirmed. All staff are required to work a probationary period at the home. Time was spent with two members of staff one of whom is a new member of staff. Both people said they enjoy working at the home, and both were very enthusiastic about their work. The new member of staff said she is being well supported by the staff, the manager and deputy manager since she started working at the home. Staff records were checked and evidence was seen to demonstrate that all employment procedures are followed and all checks are completed. Evidence of identification was also available. The registered manager said that staff are being supervised but the records do not reflect this. The manager works shifts with all members of the staff team but does not formally record any direct supervision that takes place. The supervision of staff could be shared if the deputy was to undertake supervision training. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 22 All staff have their own employee handbook and the manager works through policies and procedures with all staff. Staff on duty confirmed this. This meets a requirement of the previous inspection. The manager confirmed that all staff have now been issued with a copy of the home’s written grievance and disciplinary procedures. This meets a requirement of the previous inspection. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is managed in an open and positive way. Yunicorn Ltd monitor the home in various ways to ensure that the service continues to develop as people who use the service want and that the home remains a safe place to live and work in. EVIDENCE: The manager, Loraine Summers has been in post since October 2005. Loraine has previous experience as a registered manager of homes for the elderly, including supporting people with mental health difficulties. Loraine has undertaken a range of relevant training courses that includes Autism, first aid, health and safety, fire training, communication, dementia care mapping, and person centred planning. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 24 A deputy manager supports Loraine. Management responsibilities include organising day-to-day activities, health and safety promotion, staff supervision and induction. Staff confirmed that the manager is approachable and supportive. Staff said they are able to talk to the manager at any time. The provider’s monthly visits are one of the ways that Yunicorn monitors the service and how the home is being run. These visits include interviews with staff and people who use the service. An audit of relevant aspects of the service, including records, environment, complaints received, finance and safety is completed. Any actions that may be needed to address shortfalls are specified. A meeting is planned which will involve the sister home to complete an annual review of the service for 2007. The report from this review will include views on the service from people who use the service, stakeholders and interested parties. A copy of the report and a development action plan should be sent to CSCI. Records show that monthly checks are completed. Staff are undertaking all mandatory health and safety training topics. Generic risk assessments are in place. The Environmental Health Officer (EHO) has visited since the previous inspection. The home has a new record book and the accompanying training to complete to comply with EHO regulations. Fire training is completed quarterly. The fire officer completed and inspection of the premises 14/05/07. The registered manager said that fire safety is discussed regularly on shift and in staff meetings. Staff confirmed this takes place, but the records do not provide evidence for this. The procedure to be followed in the event of accidents or in the event of a service user becoming missing has been amended and meets the requirement of the previous inspection. The registered manager’s job description has been reviewed and revised in order to reflect all of the responsibilities outlined in Standard 37.3. This meets the requirement of the previous inspection. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 25 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 Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 3 X Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? No 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. Standard Regulation Requirement Timescale for action 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. YA19 2. 3. 4. YA39 5. YA42 YA20 YA36 Refer to Standard Good Practice Recommendations A network of professional support should be established which can respond as complex situations arise. A list of specimen signatures of all staff should be included in the medication administration record file. Records of the support and supervision of staff should be completed to demonstrate that regular supervision is taking place. A copy of the service review report and the development plan should be sent to CSCI when completed. The registered manager should record all fire safety training for staff on their individual training records. Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 27 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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hawthorns, The DS0000035065.V334587.R01.S.doc Version 5.2 Page 28 - 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!