Inspection on 12/05/05 for Holly Tree Lodge

This inspection was carried out on 12th May 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

Holly Tree Lodge 03/07/07

Holly Tree Lodge 22/01/07

Holly Tree Lodge 23/06/06

Holly Tree Lodge 21/07/05

Holly Tree Lodge 18/08/04

Holly Tree Lodge 13/04/04

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

CARE HOMES FOR OLDER PEOPLE Hawthorne House Sceptone Grove Shafton Barnsley S72 8NP Lead Inspector Jayne Barnett-Middleton Unannounced 12 May 2005 08:30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Hawthorne House Version 1.10 Page 3 SERVICE INFORMATION Name of service Hawthorne House Address Sceptone Grove Shafton Barnsley S72 8NP 01226 712 399 01226 712 399 None Prime Care 4 You Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Manager Position Vacant PC Care Home Only 37 Category(ies) of DE (E) Dementia Over 65 37 places registration, with number of places Hawthorne House Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing levels must be maintained at, at least, the levels specified by `The Residential Forum Care Staffing in Care Homes for Older People` book, published April 2002. Date of last inspection 18 August 2004 Brief Description of the Service: Hawthorne House is a home for people with Dementia. It is on a small residential estate in the village of Shafton. There is a small car parking area and adequate roadside parking. The home is a two storey building with a lift servicing both floors. There is adequate space to enable service users to move freely and safely around the home. All areas are accessible to people who use wheelchairs. The home has an enclosed garden area accessible from the main lounge. In addition to the communal lounges, there is a visitors lounge for service users to see their visitors in private. Hawthorne House Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 08.30 a.m to 3.45 p.m. Due to the mental health of service users it was difficult for them to give an opinion of the care that was offered, however, eight staff, one visiting professional and five relatives were spoken to. A sample of records was examined and a partial inspection of the building was carried out. Throughout the inspection positive and professional relationships were observed between staff and service users. The manager had alternative commitments on the day but was available at the end of the day to receive feedback. It should be acknowledged that the manager had been in post for only four weeks and that he had identified the majority of requirements that were needed to ensure that the home met the required standards. The manager confirmed that a new owner will soon be taking over the home and there are plans to invest money into the home to improve the quality of environment. The inspector wishes to thank the staff for their time and assistance throughout the day and the manager for being available to receive feedback. What the service does well: All relatives said that the quality of care was “very good” and described the staff team as “caring”. The staff had an excellent knowledge of service users physical and emotional needs and was able to clearly demonstrate the specific care that they offered service users to maintain their health. Throughout the day staff were observed to be treating service users with dignity and respect. It was evident that service users who required help to wash and dress had been assisted with this and all service users were clean and appropriately dressed. A choice of menu was provided and specific dietary needs were catered for. The meal served on the day was very well presented and looked appetising. One visitor who always stayed for lunch said that the food was “always very good”. All relatives spoke positively about the staff team and stated that their relatives were “always well cared for”. The new manager was aware of the majority of requirements that were needed to ensure that the home met the required standards and was in the process of identifying short term objectives. Hawthorne House Version 1.10 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hawthorne House Version 1.10 Page 7 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 Standards Statutory Requirements Identified During the Inspection Hawthorne House Version 1.10 Page 8 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 standard(s) 1 and 3. Prospective service users and their relatives were provided with the majority of information that they needed. Service users were not admitted to the home without their needs being assessed. EVIDENCE: A Statement of Purpose and Service Users Guide were available, however they needed reviewing to ensure that they included all of the required information, to provide service users and their relatives with the information that they needed to make an informed choice about living at the home. A full needs assessment was carried out for all service users prior to their admission. Service users and or their representatives had been included with the drawing up of these plans. This confirmed that the service was appropriate for the service user, and provided staff with the information to formulate an individual plan of care. The home does not provide an intermediate care service. Hawthorne House Version 1.10 Page 9 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 standard(s) 7,8,9,10 and 11. Care plans were in place for all service users. However they had not been reviewed on a regular basis and did not clearly evidence that the healthcare needs of service users had been monitored. Controlled drugs were not being stored appropriately and extra care was needed to ensure that all medication administered was signed for. Service users were cared for in a manner that respected their dignity and privacy. EVIDENCE: Two Care plans set out in detail the action that was required by staff to ensure that all aspects of service users care needs were met. The Care plans had not been reviewed on a regular basis to reflect the changing care needs of the service user. Care staff maintained daily records of service users health, but these required more detail, to ensure that the specific needs and care given to service users could be monitored. Records of healthcare visits were maintained and these evidenced that other healthcare professionals, e.g. general practitioner, chiropodist and optician, were visiting service users. One healthcare record indicated that the service user had not received a chiropody visit for almost a year. The manager confirmed that the chiropodist did visit the home on a regular basis. Hawthorne House Version 1.10 Page 10 However, records of these visits needed to be kept up to date, to ensure that that the healthcare needs of service users could be monitored. Nutritional screening was undertaken for service users on admission. Weight monitoring records were in place, which indicated that service users were not being weighed on a regular basis. One weight monitoring record demonstrated that the service user had lost weight, however there was no further record to demonstrate that their weight had been subsequently monitored. The staff interviewed had an excellent knowledge of service users physical and emotional needs and were able to clearly demonstrate the specific care that they offered service users to maintain their health. Throughout the day staff were observed to be treat service users with dignity and respect. It was evident that service users who required help to wash and dress had been assisted with this and all service users were clean and appropriately dressed. All relatives said that the quality of care was “very good”. One relative who had been visiting the home for many years stated that he had always observed service users to be “well cared for”. One visiting health care professional confirmed that the staff had followed the advice that had been given to promote and maintain the residents health and that “their health has improved”. There was a policy and procedure to ensure that staff adhered to safe practices regarding medication and the protection of service users. The recording and storage of medication was checked on a sample basis. Medication had been administered to one service user .A record (signature) to confirm the administration, had not been made. Controlled drugs were not being stored in a metal cupboard to comply with the Misuse of Drugs Act. There was a controlled drugs register, however another member of staff had not always witnessed the administration of controlled drugs. Staff had not received medication training, which promoted the safe administration of medication. The manager confirmed that training had been arranged to take place in the near future. The manager confirmed that the policy and procedure on death and dying had not been updated to include information of the procedure to be followed in the event of a sudden death. Hawthorne House Version 1.10 Page 11 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 standard(s) 12,13 and 15. A programme of activities was in place that was appropriate for the needs of service users. Service users were able to receive visitors at any reasonable time. A good choice of menu was offered and specific dietary needs were catered for. EVIDENCE: An activity co-ordinator had recently been employed and a programme of activities had commenced which included Bingo, crafts and memory games. There was an activities room on the second floor, which was spacious and brightly decorated. One member of staff commented that service users “enjoyed” spending time in the lounge. Several relatives said that they had been invited to events and social evenings with an entertainer. They said that they had enjoyed these events, although none had taken place for sometime. Care plans checked contained an excellent “Life History” section which demonstrated that staff had taken the time to find out service users previous occupations, family history and their interests. Service users were observed to be receiving visitors throughout the day and it was evident that the staff had positive relationships with the relatives of service users. Hawthorne House Version 1.10 Page 12 A choice of menu was provided and specific dietary needs were catered for. The cook demonstrated a good knowledge of service users likes, dislikes and individual needs. She confirmed that due to the mental health of service users they were not always able to express their ideas as to what choice of food they would like. However, she confirmed that she had recently reviewed the menu based on feedback from the staff and by generally observing meal times. One visitor who always stayed for lunch said that the food was “always very good”. The meal served on the day was very well presented and looked appetising. Service users who needed help with feeding were offered assistance in a sensitive and discreet manner, which maintained their dignity. Hawthorne House Version 1.10 Page 13 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 standard(s) 16 and 18. The complaints procedure was clear and accessible. Complaints made by service users and their relatives were listened to and action was taken to deal with complaints promptly. There was an adult protection procedure. Some staff required Adult Protection training. EVIDENCE: The complaints procedure ensured that service users and their relatives were aware of how to make a complaint and who would deal with them. Relatives stated that they were satisfied with the care provided. They confirmed that they had no complaints, however they would speak to the manager or staff should they have any concerns regarding any aspect of their care. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. Some staff had not received Adult Protection training to enable them to identify and report any allegations or incidents of abuse to service users. There were no allegations of abuse. All relatives described the staff as “caring” and “very good”. Hawthorne House Version 1.10 Page 14 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 standard(s) 19, 21,25 and 26. In the main the home was clean and tidy. The communal areas were bright and pleasantly decorated. Some areas were due for redecoration. There was insufficient domestic staff to provide a consistent level of cleanliness. EVIDENCE: In the main the home looked clean and tidy. The home had plenty of space for service users to walk about unhindered in a safe environment. The home had a dining room, a visitor’s lounge and a main lounge on the ground floor. A lounge and an activities room were on the first floor. All communal areas were bright, pleasantly decorated and presented a homely environment. The corridor walls and doors on the ground floor were due for redecoration. The walls were grubby and the paintwork chipped, which did not promote a clean environment. The home had sufficient toilets and bathing facilities, which were close to service users bedrooms and lounges. The toilets were due for redecoration; the walls and paintwork were worn, which presented a dull environment. Hawthorne House Version 1.10 Page 15 Due to one domestic vacancy and domestic staff assisting with care duties, the domestic staff stated that it was difficult to maintain a consistent level of cleanliness. They confirmed that during their days off there was often no domestic cover and that the cleaning work would “build up”, leaving little time for deep cleaning carpets and other duties. The domestic staff confirmed that they were provided with sufficient cleaning materials to carry out their duties, however the vacuum cleaner was domestic in design and was not appropriate for industrial use. The manager confirmed that the domestic post had been advertised and that he was in the process of collating a list of equipment that was needed for the new owners. Previous requirements to replace a dining room window and to provide guards to radiators had been met. Hawthorne House Version 1.10 Page 16 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27 and 29. The staffing levels did not meet the Residential Forum Staffing levels. A recruitment policy and procedure was in place, however staff had commenced employment without the required checks being undertaken. EVIDENCE: The staffing levels did not meet the Residential Forum Staffing levels, which is a condition of the homes registration. The staff stated that due to short-term sickness and vacancies they often worked “short staffed” which gave them little time to provide the emotional care that they believed service users deserved. All relatives spoke positively about the staff team and stated that their relatives were “always well cared for” and “never neglected”, however they raised concerns about the numbers of staff that were provided on some shifts and stated that at times the staff were “pulled out”. Some staff felt that the current rota system was “unfair” and that “unsociable” shifts (weekends) were not always allocated equally. The manager said that positively two experienced staff had recently commenced employment at the home and that a further two staff were due to commence employment subject to references and a successful Criminal Records Bureau check. Hawthorne House Version 1.10 Page 17 A recruitment policy and procedure was in place. One file checked contained a range of information including two references, declaration of health and qualifications/training. The files did not contain a full employment history of the employee. One staff member confirmed that they had commenced employment without a police check. They did confirm that they had completed the required information and that they anticipated a clear disclosure within the near future. The file checked needed reorganising to ensure that the required information was easy to track. One staff member confirmed that they had received appropriate support and training on their employment, to enable them to safely and appropriately care for service users. Hawthorne House Version 1.10 Page 18 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,36 and 38. A new manager was in post and was aware of the majority of requirements that were needed to ensure that the home met the required standard. Staff did not receive formal supervision. Areas of development were required to ensure that the health, safety and welfare of service users and staff were protected. EVIDENCE: The manager had been in post for only four weeks. He was a qualified nurse and had previous experience of working within the caring profession. The manager was undertaking a level 4 National Vocational Qualification in management and care. The manager was aware of the majority of requirements that were needed to ensure that the home met the required standards and was in the process of identifying short term objectives. Hawthorne House Version 1.10 Page 19 Relatives said that they were aware that a new manager had been employed and that they would like the opportunity to meet with him to “get to know him”. The staff said that they received supervision on a daily basis. However, they did not receive formal supervision to discuss care practices and to identify career and training development needs. Records to confirm that gas appliances, electrical systems, emergency lighting and emergency call systems to promote a safe environment were not accessible and therefore this previous requirement has been carried forward. The manager confirmed that fire systems were checked weekly. He confirmed that Fire awareness training was planned to ensure that staff were conversant with fire safety and the action to take in the event of a fire. The boiler within the kitchen of the home was in need of repair and had been out of order for some time. The cook confirmed that kettles were provided to enable her to make hot drinks for service users, however that this proved time consuming during meal times. The staff confirmed that they had recently received COSHH (Control of Substances Hazardous to Health Regulations) training. They stated that they did not have safety data information for cleaning materials to ensure that they were using them appropriately and safely. Hawthorne House Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 2 x 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 1 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 2 x 3 x x x 2 2 STAFFING Standard No Score 27 1 28 x 29 2 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 3 x x x x 2 x 2 Hawthorne House Version 1.10 Page 21 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 OP1 Regulation 4 Requirement The statement of purpose and service user guide must be amended to include all information required. regulations. (Timescale of 10th November 2004 not met) Care staff in consultation with the service user and representative must review service users care plans at least once a month.(Time scale of 10th November 2005 not met) Records of healthcare visits to service users (i.e Chropodist) must be maintained. Service users must be weighed on a regular basis. Records of weight loss/gain must be maintained and appropriate action must be taken. Controlled drugs must be stored in compliance with the Misuse of Drugs (safe Custody ) Regulations 1973. The administration of Controlled Drugs must be witnessed by another designated member of staff. All medication administered to service users must be signed for. Staff who deal with medication Version 1.10 Timescale for action 31st July 2005. 2. OP7 12,15 1st June 2005. 3. 4. OP8 OP8 12,13 12,13 1st June 2005. 1st June 2005. 5. OP9 13,17 1st June 2005. 1st June 2005. 12th May 2005. 30th June Page 22 6. OP9 13,17 7. 8. OP9 OP9 13 13,17 Hawthorne House 9. OP11 12 10. OP18 13,18 11. OP26,27 13,18 12. OP27 13,18 13. OP29,37 19 14. OP29 19 15. OP36 18 16. OP38 13,17 17. OP38 13,23 must receive accredited medication training. (Timescale of 10th November 2005 not met.) The policy and procedure on death and dying must be reviewed to include information of the procedure to be followed in the event of a sudden death. (Timescale of 10th November 2005 not met) All staff must receive training in adult abuse and protection (Timescale of 10th November 2005 not met) Sufficient domestic staff must be employed to ensure that a consistent level of hygiene is maintained. Sufficient Care staff must be employed in such numbers to meet the needs of service users, in line with the homes condition of registration. The home must operate a thorough recruitment procedure as required by the regulation.(Timescale of 10th November 2004 not met) Staffs’ personal files must contain a record of the employee’s full employment history. Any gaps in employment must be accounted for and recorded. All care staff must recieve formal superversion at least six times per year (Timescale of 10th November 2004 not met) All systems within the home must be serviced and maintained to ensure that they are in good working order including gas appliances, electrical circuits, emergency lighting and emergency call systems. All staff must have fire awareness training (Timescale of Version 1.10 2005. 1st July 2005. 1st July 2005. 1st July 2005. 31st July 2005. 1st June 2005. 1st July 2005. 1st August 2004. 1st August 2005. 30th June 2005. Page 23 Hawthorne House 18th August 2004 not met) 18. 19. 20. 21. OP38 OP38 16 13 The boiler in the kitchen must be repaired. Safety data information must be provided for cleaning material used at the home. 31st May 2005. 1st June 2005. 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. 3. 4. 5. 6. 7. 8. 9. Refer to Standard OP12,13 OP19 OP21 OP27 OP28 OP29 OP31 OP32 OP38 Good Practice Recommendations Social evenings/Entertainment should be incorporated into the programme of activities (Should funds be available). The corridor on the ground floor should be redecorated within the next six month. Toilet facilities on the ground floor should be redecorated within the next six months. The staff rota should be reviewed to ensure that weekends are allocated to staff on an equal basis. A minimum of 50 of care staff should attain NVQ Level 2 in care by 2005. Staff files should be reorganised to ensure that information is easily accessible. The manager should attain the Managers Award by 2005. Relatives should be given the opportunity to meet with the manager. The vacumn clean should be replaced. Hawthorne House Version 1.10 Page 24 Commission for Social Care Inspection Ground Floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR 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. 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