Inspection on 21/07/05 for Holly Tree Lodge

This inspection was carried out on 21st July 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 12/05/05

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 21 July 2005 09:15 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 J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Hawthorne House Address Sceptone Grove Shafton Barnsley S72 8NP 01226 712 399 None 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) Vacant PC Care home only 37 Category(ies) of DE(E) - Dementia - over 65 (37) registration, with number of places Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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 12 May 2005 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 J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out from 09.15 am to 3.00 pm. The inspection focussed on checking that previous requirements had been met and to seek the views of relatives and staff. Due to the mental health of service users it was difficult for them to give an opinion of the care that was offered, however seven staff, three relatives and the manager 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 inspector wishes to thank the staff and manager for their time and assistance throughout the inspection process. What the service does well: What has improved since the last inspection? The Statement of Purpose and Service Users Guide had recently been reviewed, to ensure that they contained all of the required information and copies had been submitted to the C.S.C.I. The Care plans had been reviewed on a regular basis to reflect the changing care needs of the service user and the weight of service users had been monitored on a regular basis. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 Page 6 There were major improvements to the recording and storage of medication. Controlled drugs were being stored and administered as required and the drug administration records were very well maintained. Senior staff responsible for administering medication had recently completed accredited training, to ensure that they were administering medication appropriately. The policy and procedure on death and dying had been updated to include the procedure to be followed in the event of a sudden death. A copy of this had been submitted to the C.S.C.I. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level and the employment application form had been reviewed to ensure that all information requested from the employee met the required standard. Formal supervision had commenced for care staff, to discuss care practices and to identify career and training development needs. 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. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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 J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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 information that they needed, to make an informed choice about living at the home. Service users were not admitted to the home without their needs being assessed. EVIDENCE: A Statement of Purpose and Service Users Guide were available, to provide service users and their relatives with the information that they needed to make an informed choice about living at the home. These had recently been reviewed to ensure that they contained all of the required information and copies had been submitted to the C.S.C.I. 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 J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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. Service users individual needs were assessed. Care plans and daily care notes were improved, however futher input was needed to ensure that they met the required standard. A policy and procedure to ensure that staff adhered to the safe administration of medication was in place. Service users privacy and dignity was respected The policy and procedure on Death and Dying, had been reviewed to meet the require standard. Care plans did not evidence that the service users representative had been consulted in relation to their relatives preferred funeral arrangements. EVIDENCE: Three 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 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. There were improvements to the content of these records, however more detail was required, to ensure that the specific needs and care given to service users could be monitored. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 Page 10 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 file checked demonstrated that the service user had received advice from a general practitioner, due to their physical health, however records of the advice and action taken had not been recorded 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 being weighed on a regular basis. 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. There were major improvements to the recording and storage of medication. Controlled drugs were being stored and administered as required and the drug administration records were very well maintained. The manager confirmed that senior staff responsible for administering medication had recently completed accredited training, to ensure that they were administering medication appropriately. The policy and procedure on death and dying had been updated to include the procedure to be followed in the event of a sudden death. A copy of this had been submitted to the C.S.C.I. Care plans checked did not evidence that the service users representative had been consulted about their preferred funeral arrangements, to ensure that any specific requests and spiritual needs could be respected. Service users were observed to be receiving personal care in a manner that respected their privacy and dignity. Interactions between staff and service users appeared respectful and caring. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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. The daily routines within the home were flexible and promoted service user choice. The programme of leisure and social activities available required improving. Service users were encouraged to maintain contact with their family, friends and the local community as they wished. A good choice of menu was offered and special dietary needs were catered for. EVIDENCE: The daily routines within the home were flexible. Several service users were observed to be spending time in the lounges whilst others were freely walking around the home. There was an activities room on the second floor, which was spacious and brightly decorated. Activity equipment including art and crafts suitable for the needs of service users was provided. An activity worker was employed, however due to illness a routine programme of activities was not being offered. The staff commented that due to staff shortages there was minimal time to provide the emotional care that service users required. The staff were in the process of organizing a summer fete, to raise funds for trips and entertainment. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 Page 12 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. A choice of menu was provided and specific dietary needs were catered for. The cook was in the process of reviewing menus based on service users likes and dislikes. 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 J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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. Staff were conversant with the homes adult protection policy but they had not received 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. There was an adult protection policy and procedure that promoted the protection of service users from harm or abuse. The staff confirmed that they were aware of the homes adult protection policy. However, staff had not received adult protection training to enable them to identify and report any allegations or incidents of abuse to service users. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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) 19,21,23 and 26. The home was clean and tidy. The communal areas were bright and pleasantly decorated. Some areas within the home were due for redecoration. Service users were provided with an environment that was safe, accessible and homely. EVIDENCE: The home was clean and tidy. There was 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 walls and paintwork on the ground floor corridor were looking worn and were in need of redecoration. The manager said that there were plans to redecorate these areas within the near future. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 Page 15 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 and floor coverings were stained. One domestic vacancy had been recruited to subject to recruitment checks, and it was anticipated that extra cleaning cover would promote a consistent level of cleanliness. The domestic staff had been provided with a new vacuum cleaner and cleaning trolley, which the domestic staff confirmed was much better. Several bedrooms were checked and all were clean and tidy. All bedrooms seen had been personalised by the service user with small items of furniture, photographs and mementoes, which encouraged service users to retain their own identity. All areas within the home were clean and tidy, which promoted the health of service users. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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) 27,29 and 30. Staff vacancies had been recruited to however; due to short term sickness the staffing levels did not meet the Residential Forum Staffing levels. A training and development programme was in place. Staff required refresher training, to enable them to meet the needs of service users. The home operated a recruitment procedure, which needed some amendments to promote the protection of service users. EVIDENCE: All relatives spoke positively about the staff team and described them as “friendly”, “good” and “helpful”. Staff vacancies had been recruited to and two bank staff had been employed. One relative commented that there was “some improvement” to the number of staff that was on duty when they visited. However, the staffing levels did not meet the Residential Forum Staffing levels, which is a condition of the homes registration. Staff rotas checked demonstrated that the manager was planning the staff rota to ensure the required minimum of staff was provided, however short-term sickness was creating a shortfall. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 Page 17 A recruitment policy and procedure was in place. Two files checked for recent employees contained a range of information including two references, declaration of health and qualifications/training. The employment application form had been reviewed to ensure that all information requested from the employee met the required standard. The manager did confirm that existing staff files still required some work to ensure that the employee’s full employment history was recorded. All staff employed had undertaken a Criminal Records Bureau Check at the enhanced level. A training and induction programme for staff was in place to enable them to meet the assessed and changing needs of service users. Staff confirmed that they had attended various training courses that included food hygiene and moving and handling. Staff confirmed that they were in need of First Aid refresher training, to enable them to keep up to date with changing practices and legislation. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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) 33,35 and 38. Service users financial interests were safeguarded by the procedures at the home. Policies and procedures were in place, which promoted the health, safety and welfare of service users and staff. Staff required First aid and Fire refresher training, to enable them to keep up to date with changing practices and legislation. A routine programme of maintenance was in place, but electrical and gas appliances were in need of servicing. EVIDENCE: The manager had been in post almost three months and during this time had worked towards ensuring that the majority of previous requirements were met. He is a qualified nurse and has previous experience of working within the caring profession. The manager was undertaking a level 4 National Vocational Qualification in management and care. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 Page 19 Service users were encouraged to manage their own finances, which enabled them to maintain their independence. Arrangements were in place for service users who were unable to manage their monies due to their mental health. Monies were securely stored and records checked evidenced that service users were able to access their monies for hair care and personal items as they wished. The two records checked were well maintained and safeguarded the financial interests of service users. A recommendation for two staff to check finances on a regular basis was made, to promote the protection of service users. The staff received supervision on a daily basis and formal supervision had commenced to discuss care practices and to identify career and training development needs. A handyman was employed and a routine programme of maintenance was in place to promote a well maintained environment. Fire systems and moving and handling equipment had been routinely serviced, however, electrical systems and gas appliances were in need of servicing, to promote a safe working environment. 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. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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. 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 3 x 3 x x N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 2 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 x 15 3 COMPLAINTS AND PROTECTION 3 x 3 x 3 x x 3 STAFFING Standard No Score 27 2 28 x 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 2 x x 3 x 3 x x 2 Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 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 OP7 OP11 Regulation 13 Requirement Service users preferences regarding funeral arrangements must be recorded on their care plan. Daily Care Records must be more detailed to reflect the care needs of service users (Timescale of 1st June 2005 not met). Records of healthcare visits to service users must be maintained (Timescale of 1st June 2005 not met). A consistent programme of activities, suited to the needs of service users, must be provided. All staff must receive adult protection training and guidance (Timescale of 1st November 2005 not met). Sufficient Care staff must be employed in such numbers to meet the needs of service users, in line with the homes condition of registration. Staff files must contain a record of the employee’s full employment history (Timescale of 1st July 2005 not met). All senior staff/Designated Timescale for action 30th August 2005. 30th August 2005. 2. OP8 12,13 3. OP8 12,13 30th August 2005. 30th August 2005. 1st September 2005. 30th August 2005. 4. OP12 16 5. OP18 13 6. OP27 13,18 7. OP29 19 1st September 2005. 1st Page 22 8. OP30 OP38 13 Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 9. OP38 13,17 10. OP38 13,23 person in charge must receive First Aid refresher training. All systems within the home must be serviced and maintained to ensure that they are in good working order including gas appliances and electrical appliances (Timescale of 1st July 2005 not met). All staff must have fire awareness training (Timescale of 1st July 2005 not met) September 2005. 1st September 2005. 31st August 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. Refer to Standard OP19 OP21 OP21 OP28 OP31 OP35 Good Practice Recommendations 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 toilet floor covering on the ground floor should be replaced within the next six months. A minimum of 50 of care staff should attain NVQ Level 2 in care by 2005. The manager should attain the Managers Award by 2005. Two staff should check service users finances on a monthly basis. Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 Page 23 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. Extracts may not be used or reproduced without the express permission of CSCI Hawthorne House J51 S36220 Hawthorne House V239360 21.7.05 UI Stage 4.doc Version 1.40 Page 24 - 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. 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