Inspection on 22/01/07 for Holly Tree Lodge

This inspection was carried out on 22nd January 2007.

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 23/06/06

Holly Tree Lodge 21/07/05

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 South Yorkshire S72 8NP Lead Inspector Christine Rolt Key Unannounced Inspection 22nd January 2007 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hawthorne House DS0000036220.V325076.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 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 DS0000036220.V325076.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorne House Address Sceptone Grove Shafton Barnsley South Yorkshire S72 8NP 01226 712399 01226 718054 none None Prime Care 4 You Limited 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) Vacant Care Home 37 Category(ies) of Dementia - over 65 years of age (37) registration, with number of places Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 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. 23rd June 2006 Date of last inspection 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. 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. The weekly fee was in line with local authority payments at £356.50 per week. Hairdressing, chiropody, taxis, dry cleaning, and personal items were not included in the weekly fee and were charged separately. The contract and draft payment schedule supplied during the site visit on 22nd January 2007 provided this information. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prime Care 4 You Limited owns this home but at the time of this inspection, Red Rose Care Limited was in the process of buying the company. This was a key inspection and comprised information already received from or about the home and a site visit. The site visit was from 9.30 am to 5.45 pm on 22nd January and from 9.25 am to 3.55 pm on 24th January 2007. The acting manager provided assistance throughout the two days. The area manager sent her apologies but communicated by telephone of the company’s intentions for improving the home. The majority of residents were seen and chatted with during the site visit. Three residents were tracked throughout the two days. Three members of staff, two relatives and a GP were interviewed. Surveys and questionnaires were sent to 10 residents, 10 relatives and 10 staff. Only three questionnaires were completed and returned; two from members of staff and one from a relative. Care practices were observed, a sample of records was examined and a partial inspection of the building was carried out. The inspector wishes to thank the acting manager, area manager, staff, residents, relatives and the GP for their assistance and co-operation. What the service does well: What has improved since the last inspection? Since the last key inspection, work was in progress to improve the service. A Statement of Purpose had been produced. Policies and Procedures had been implemented. Residents’ files had been updated with new documentation to cover all aspects of residents’ cares needs e.g. risk assessments, weight monitoring charts, and health care visits. However, the completion of some documents still needed improvement. See section below. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 6 The lounge, some bedrooms and all lavatories had been refurbished and work was ongoing to improve the whole environment. Mandatory health and safety training had commenced and training in dementia was planned for all staff. Fire drills and fire training were being done weekly to ensure that staff were fully conversant with the procedures. Staff meetings had commenced. The home, which had been lacking leadership, had a new acting manager who was supported by an area manager. The ethos within the home was changing to be more client centred. 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. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not provide intermediate care. Prospective residents had some of the information they needed to enable them to make an informed choice about where to live. All residents did not have contracts/statements of terms and conditions and information relating to items not included in fees was not clear. Assessments were generally carried out for residents but not all information was included. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 9 EVIDENCE: The acting manager said that prospective residents and their families were shown around the home, their questions were answered and they were given a copy of the Statement of Purpose. Copies of the Statement of Purpose were seen in residents’ bedrooms and the main entrance. The Statement of Purpose covered all the main areas required by regulation but some areas needed expanding to provide more specific details. The home did not have a Service User Guide and this was discussed with the acting manager. On the second day of the site visit, the area manager said that work had already commenced on amending the Statement of Purpose and producing a Service User Guide. The inspection report was displayed in the entrance foyer. Four residents’ contracts/terms and conditions were requested for checking. The acting manager said that one resident did not have a contract as his placement was still being reviewed. Of the remaining three residents, only one contract could be supplied thus two residents had no contracts. The acting manager also supplied a template of the payment schedule that provided a breakdown of fees. The area manager said that all residents would be issued with this document. However, it was noted that some information in this document did not correlate with information in the original contracts i.e. items or services not covered by the fees. Also documentation stated the company was Red Rose Care Ltd, whilst the company that owns this home is Prime Care 4 You. The need to amend the documentation was discussed with the acting manager and the area manager. Residents’ Assessments of Needs forms differed because the company was introducing new documentation. However, on those seen, neither type had been completed fully to cover all aspects of need, therefore all needs had not been assessed and some documents were not dated. One resident had no assessment available and there was no explanation of the reasons. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. Individual care plans did not provide sufficient details of residents’ health, personal and social care needs and changing needs were not reflected in their care plans. Residents’ health care needs were met. Medication procedures needed tightening to ensure that residents were protected. Residents’ privacy and dignity was generally respected but improvements could be made. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 11 EVIDENCE: Four care plans were checked. These files had been updated to include a good range of forms and templates suitable for recording information of residents’ care needs. However the information provided was not sufficient to ensure that the needs were being addressed and met. (See also Standard 3 re Assessments.) A relative commented that their parent’s teeth were never cleaned although verbal requests had been made to the staff. The care plan contained no information about this. Care plans needed more details specific to individual residents including better detail of physical care needs and how these were to be met. Care records provided very general comments and were not specific enough to ensure that all needs had been met (i.e. physical, health, emotional and social) and did not provide a trail of evidence for cross referencing each section of the care plan. Although staff were key workers, they could not demonstrate, when asked, that they had good knowledge of the residents and said that they did not use care plans as working documents therefore would not recognised if risk assessments and care plans had changed unless informed verbally. The new management were trying to overcome this problem by providing training, and teaching staff of their responsibilities to residents. Healthcare visits were now included in the care plans. Referrals to health care professions were now being made and dental visits were to commence and carried out six monthly according to the acting manager. The acting manager was also building relationships by attending meetings with local GP practices to ensure that residents received the best care. Residents were now being weighed and records were kept on their care plans. Risk assessments were now included in care plans. However risk assessments and care plans were not always reviewed following accidents or falls to determine whether they were still relevant. This was discussed with the acting manager. Accidents were recorded in the accident book. The acting manager said that a system had been introduced to monitor the number of accidents to determine the residents most at risk, causes of accidents and whether any patterns were formed. The acting manager was advised to supplement this with individual monitoring of residents following accidents or falls to ensure that injuries not apparent at the time of the accident were highlighted quickly. A 72-hour monitoring sheet was recommended. Residents’ files contained inventories of personal clothing and items, but the information was not specific and there was no information of personal furniture and equipment. This was discussed with the acting manager. Care plans were reviewed monthly but not in consultation with the resident or their representative. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 12 Medication reviews had been carried out on residents who were on controlled drugs and now none of the residents were on controlled drugs and all this medication had been returned to the pharmacy. All medication was stored safely. Medication that required refrigeration was kept in a refrigerator in the medication room and records of the temperature were kept. Medication for three residents was checked. Medication tallied with the Medication Administration Record sheets. The procedure for booking in medication did not include the date of receipt of the medication and this was brought to the attention of the acting manager. It was also strongly recommended that handwritten entries on the MAR sheet were countersigned and that any instructions for administration were included. At the time of this site visit, residents were observed being treated with respect and dignity. Risk assessments had been carried out for residents to have keys to their bedrooms, but not for lockable facilities, and not all bedrooms had these facilities. This was discussed with the acting manager. (See also Standard 24) Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents’ lifestyle in the home did not match their expectations and preferences. They were encouraged to maintain contact with their family and friends, but had no contact with the local community. Residents were not always empowered to make choices and have control over their lives. Residents received an appealing, balanced diet but were not made aware of choices available. Dietary needs were catered for. EVIDENCE: The majority of residents spent the day sitting in the lounge and some were asleep. One resident was seen walking around the home. There were no activities taking place. The acting manager said that they provided dominoes, jigsaws and played bingo. She also added that staff sat and talked to residents and also did manicures and hand care with them. However, there was no activity programme and no group activities suited to meet the social needs of the residents. Also, there was no records on residents’ care plans to verify that Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 14 staff spent time with residents. The acting manager said that they had contacted families for information of residents’ past interests and life histories with a view to providing more activities and stimulating individual interests. She also added that they were looking at trips out into the community but this had not yet commenced. Relatives said that they could visit the home whenever they wanted and one relative said that he visited every day and was always made welcome. The acting manager said that residents got up and went to bed when they wanted but they were encouraged to get up by 11.00 am to ensure they received sufficient sustenance and their medication regimes were not affected. Relatives considered that residents had choices in their lives, but interviews with staff did not confirm that they always offered this. The need for staff training to ensure that residents were encouraged and empowered to make choices was discussed with the acting manager. Daily information of meals was not available to residents. The menu board was blank. The acting manager said that alternatives were provided if the resident did not want the meal on offer. When this was discussed with the area manager, she was surprised and named some of the alternatives meals that should have been available to enable residents to make a positive choice. This was discussed with the acting manager. The meals seen during the site visit were well presented with a good selection of fresh produce. Residents said that they were enjoying their meals. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Relatives were confident that their complaints would be taken seriously. Residents were not fully protected from abuse. EVIDENCE: The home’s complaint procedure was displayed in the main entrance and copies were also available in the Statement of Purpose in each resident’s bedroom. Relatives said that they knew how to complain and said that they would tell the acting manager of any concerns they had. There were no complaints at the time of this site visit. The acting manager had reported one member of staff to Barnsley Adult Protection Team and this allegation was being processed at the time of this site visit. Two of the staff files checked showed certificates of attendance for adult protection training. The area manager said that the company intended for all staff to attend their own adult protection training, but because staff had a high level of training needs, it was a matter of prioritising the training, thus moving Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 16 and handling and health and safety were their top priorities. However, adult protection training was high on the list. The acting manager was advised to carry out interim in-house training of the definitions of abuse and ‘whistle blowing’. The adult protection policies and procedures were checked. There were several different ones of these on file and this information needed collating and condensing to provide a comprehensive document with clear, concise information relevant to this home. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 21, 22, 24 and 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was clean and hygienic and improvements were being made to the environment. There were sufficient bathrooms but not all were fit for purpose. Specialist equipment was provided but storage of excess wheelchairs was a problem. Some bedrooms had improved but did not have lockable facilities and un-modernised bedrooms could be maintained until refurbishment commenced. EVIDENCE: The home was in the process of being totally refurbished. There were no offensive odours. Relatives said they thought the home was clean. The lounge had been redecorated, refurnished, re-carpeted and new light fixtures were Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 18 fitted. Windows in the lounge were unscreened but the area manager said that new curtains were on order and these would be fitted as soon as they arrived. In the small lounge, the wooden window frame was rotten and needed replacing. The area manager said that the window frames were to be audited and this window frame and some of the others were to be replaced or repaired as necessary. Lavatories had improved and were much lighter and brighter by being tiled and having new flooring fitted. However, the sink in one toilet was damaged. Some bedrooms had been totally refurbished and were bright and welcoming. In two bedrooms that had not been modernised, there was water damage above the windows. These were brought to the attention of the acting manager and the area manager who said that these would be checked out to discover if there was a water leak. In the majority of the bedrooms that had not been modernised, the curtains had insufficient curtain hooks and some curtains were hanging off the rails. The acting manager said that it was the company’s aim to refurbish all bedrooms to the same high standard to those already done, however, in the interim period, the curtains need to be re-hung. Some bedrooms had lockable facilities but no keys and the newly refurbished bedrooms had no lockable facilities. The need to provide these and issue keys (subject to risk assessment) was discussed with the acting manager. (See also Standard 10) The bathrooms that were used most frequently were showing signs of wear and tear. The area manager said that these were to be refurbished. However, one bathroom was in good condition but could not be used because there was no means for residents to be able to get into the bath (which was high to prevent back injuries to staff). The water at outlets to two of the baths that were checked was very hot but there was no thermometer available to check the exact temperatures. (See Standard 38). The acting manager said that all bed linen and towels had been audited and replacements were to be provided. The acting manager and the area manager said that the corridors were to be redecorated. All corridors looked the same and one resident made a comment about having problems finding his way back to the lounge. The acting manager was advised to consider orientation when redecorating to ensure that residents could find their way around the home. It was also suggested that signs pointing the way to areas around the home e.g. lavatories, lounge and dining room would help residents. Mobility aids and equipment, i.e. wall bars, raised toilet seats, support rails, were provided to enable residents to maintain their independence although one Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 19 relative commented that the rail in one lavatory was at the wrong height for his mother. However other lavatories were available and the acting manager was looking at providing a raised seat in this toilet. The home had excess wheelchairs. Some were stored in a cupboard, some at the end of a corridor and some in the Laundry Room. Those in the Laundry Room needed moving. The laundress did not have the necessary equipment for ironing especially for bedding. The ironing board cover was torn and worn and not fit for use. She said that the iron did not get hot enough to iron properly. It was also recommended that individual baskets be provided for residents’ clean laundry. The area manager agreed to do this. No work has been carried out on the garden but according to the acting manager, the new owner was planning to carry out this work when the weather improved. This, when done, will provide another communal area for the residents. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The numbers and skill mix of staff met residents’ needs. The home’s recruitment practices needed checking to ensure that residents were supported and protected. Staff were in the process of being trained to do their jobs EVIDENCE: There were sufficient staff on duty during the two days of this site visit. Staff from a home owned by Red Rose Care Ltd and agency staff supplemented the home’s staff to cover staff shortages. The acting manager confirmed that all agency staff were checked to ensure that they had Criminal Records Bureau (CRB) disclosures and Protection of Vulnerable Adults (POVA) checks and provided written information as confirmation. The area manager verified that all new employees undertook induction training to a recognised standard (i.e. Skills for Care). The Pre-Inspection Questionnaire provided information that 46 of staff had attained NVQ Level 2 or above. During the site visit the manager said that she had checked with staff to determine who had this qualification and 50 of staff said that they had attained this qualification. However, there was no Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 21 documentation on file to support this. Two members of staff were currently undertaking this qualification. Three staff files were checked for recruitment documentation. Two of the three had CRB and POVA checks, but one did not. The acting manager said that there had been a mix up with this member of staff’s CRB and delay in receipt. The need for CRB disclosures and the provision of POVAFirst checks before commencing work was discussed. Files contained references and identification documents. There was evidence that staff were interviewed but one interview carried out by a senior carer stated that the candidate was poor with no explanation of reasons for this judgement but the candidate was subsequently employed as a current member of staff. Therefore tighter procedures need to be introduced to query judgements and explanations of why judgements have been overridden. Skills training was planned to enable all staff to understand their roles and the residents’ needs i.e. dementia. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home had no registered manager. Improvements were needed to ensure that the home was run in the best interests of residents. Residents’ financial interests were safeguarded. Residents’ health, safety and welfare were not fully promoted. EVIDENCE: The home had lacked leadership for several years and had not had a registered manager since August 2003. Prime Care 4 You owns Hawthorne House, but at the time of this inspection, Red Rose Care Ltd was in the process of buying out the company. Red Rose Care Ltd had appointed an acting manager and the Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 23 area manager supported her. Changes in work practice, training, record keeping and the environment had commenced and the home was showing some signs of improvement for the benefit of residents. The home has questionnaires for relatives and was also inviting relatives to the home to meet the acting manager and discuss any issues they had. The acting manager was advised on ways to implement a quality assurance system after these initial meetings to ensure that the home was run in the best interests of residents. The acting manager said that staff meetings had commenced and she also planned to have staff supervision sessions although these had not commenced. The area manager carried out visits and produced reports as required by regulation; however, these were not being done within the regulated timescales. The insurance certificate was up to date. Money held by the home on behalf of residents was stored safely and cash tallied with records. Receipts were available. Each transaction was countersigned as verification, which was good practice. Policies and procedures for adult protection (see Standard 18) and moving and handling were checked. The policy and procedure for moving and handling provided good, easy to read information of all aspects of moving and handling. All staff undertook moving & handling training and health & safety training on two dates in November 2006. Four staff attended Control of Substances Hazardous to Health (COSHH) training in November 2006 and this training was also arranged for the end of January 2007. Eight staff attended emergency first aid training in December 2006. Training planned for the immediate future was Equality and Diversity, Infection Control, Safe Handling of Medication and Nutrition and Health. Arrangements were being made for the cooks to undertake NVQ in Hospitality. The area manager was arranging all training and confirmed that all mandatory training would be provided for all staff. The acting manager provided records of fire drills and fire awareness training undertaken by staff. She said that this training would be held weekly until all staff had undertaken it and were deemed competent and then the frequency of this training would reduce. She also said that as part of the refurbishment new fire doors and new keypads were to be fitted. Fire extinguishers had been serviced. A repair to the hot water system was carried out in August 2006 but there was no evidence that the system had been serviced. Hot water at outlets to two baths was very hot and there was no means to check the temperatures. Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 24 The lift and the hoists had been serviced within the regulated time frames. A repair to the gas system had been carried out in October but there was no evidence that the system had been serviced. Portable Appliance Test checks were out of date. This information was passed to the area manager who said that all systems and equipment would be serviced and maintained and said that the emergency lighting, the nurse call system and the electrical circuit check were also to be done imminently. Hawthorne House DS0000036220.V325076.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 2 X 2 X 2 STAFFING Standard No Score 27 3 28 2 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 x 3 x x 2 Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 26 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 Timescale for action 09/04/07 2 OP1 3 OP2 4 OP3 5 OP7 6 OP7 Provide greater detail of how the home intends to meet the criteria of the Statement of Purpose. 5 A Service User Guide must be produced and a copy supplied to each resident. A copy must also be available for inspection by anyone who wishes to see it. 5 All residents must be issued with a contract/statement of terms and conditions (that includes fees payable, method of payment and clear information of arrangements for charging and paying for additional services) 14 Assessments must be completed fully to ensure that the home can meet all the needs of the resident. 12, 13, 15 Care Plans must be relevant to residents’ individual needs and provide details of how these are to be met. 12, 13, 15 Daily Care Records must provide specific information of how residents needs (including social and emotional needs) have been met. DS0000036220.V325076.R01.S.doc 09/04/07 19/03/07 19/03/07 19/03/07 19/03/07 Hawthorne House Version 5.2 Page 27 7 OP8 8 OP7 9 OP7 10 11 OP9 OP10 12 OP12 13 OP12 14 OP14 Requirement outstanding from or before June 2005 13 It must be demonstrated in the care plan that where a resident has had a fall or an accident, the appropriate action was taken and the resident monitored to determine if any injury was sustained. 12, 13, 15 Care plans and risk assessments must be reviewed following any accident/incident, but at least once per month, and in consultation with the residents or their representatives (where feasible) to ensure that residents’ needs are met. 12 All residents’ care plans must include up to date detailed inventories of residents’ personal property. Timescale of 22/12/06 not met 13 The correct procedures for the receipt of medication must be adhered to 12 Residents’ rights to be treated as individuals with the right to privacy must be respected, including the use of a lockable facility with key, subject to risk assessment. Timescale of 22/12/06 not met. 16 A consistent programme of activities, suited to residents’ needs must be provided. Requirement outstanding since August 2005 16 Residents must be given opportunities for stimulation through individual leisure and recreational activities both inside and outside the home and daily records must demonstrate how these needs have been met. Timescale of 19/01/07 not met 12 Residents must be encouraged to make choices and have control over their own lives. DS0000036220.V325076.R01.S.doc 19/02/07 19/02/07 19/03/07 19/02/07 19/03/07 09/04/07 09/04/07 19/03/07 Hawthorne House Version 5.2 Page 28 15 16 OP15 OP18 12 13 17 OP18 13 18 19 OP19 OP19 23 23 20 21 22 OP19 OP21 OP21 16 23 13, 23 23 OP22 23 24 25 26 27 28 OP24 OP24 OP24 OP26 OP28 23 16 16 16 18 Residents must be informed of meals and the available options. Timescale of 22/12/06 not met All staff must undertake adult protection training. Outstanding requirement from or before November 2004 The home’s adult protection policy and procedure needs collating and condensing to prove clear, concise information for the benefit of staff and welfare of residents Window frames must be audited and replaced or repaired as necessary. The garden surface must be levelled, and made safe and suitable for residents. Timescale of 19/01/07 not met. Curtains must be provided in the main lounge The damaged sink in the identified lavatory must be repaired or replaced. The identified bathroom must be made fit for purpose by the provision of means to use the bath e.g. a static hoist. Wheelchairs must be removed from the laundry and excess wheelchairs disposed of as necessary The identified bedrooms must be checked for water leaks above the windows Extra curtain hooks must be provided and bedroom curtains re-hung. Lockable facilities must be provided (and keys provided subject to risk assessment) Replace or repair the ironing equipment in the laundry Documentary evidence of staff qualifications must be provided i.e. NVQs DS0000036220.V325076.R01.S.doc 19/02/07 19/03/07 19/03/07 09/04/07 09/04/07 19/02/07 09/04/07 09/04/07 19/02/07 09/04/07 19/02/07 09/04/07 19/03/07 19/03/07 Hawthorne House Version 5.2 Page 29 29 OP29 19 30 OP29 19 31 OP31 10 32 OP33 24 33 OP33 26 34 OP38 13 35 OP38 13 36 OP38 13 All staff files must be audited to ensure that the relevant recruitment information is included including CRB and POVA disclosures for all staff. Staff designated to interview job applicants must follow the home’s policy and procedure and provide factual evidence of reasons for judgements. Application must be made for the manager to be registered with the Commission for Social Care Inspection. A Quality Assurance and Monitoring System must be implemented to review the quality of care within the home, i.e. views of interested parties, audits and maintenance of environment, services and systems used within the home. Timescale of 19/1/07 not met. The provider or his representative must produce written reports of his/her unannounced inspections of the home within the regulated timeframes. All mandatory health and safety training, including, infection control, basic food hygiene, and emergency first aid, must be up to date for all care staff. Timescale of 22/12/06 not met All systems and equipment must be serviced and maintained within the relevant regulation timeframes – specifically gas, water, and electrical systems and appliances The hot water temperature at outlets to baths must be close to 43 degrees Centigrade to ensure residents’ safety. 19/02/07 19/03/07 09/04/07 09/04/07 19/02/07 09/04/07 19/02/07 19/02/07 Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 30 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP7 Good Practice Recommendations The implementation of a 72-hour monitoring sheet for residents who have had accidents would highlight to staff that the resident was being monitored to determine if injuries had been sustained. Strongly recommended that handwritten entries on MAR sheets are countersigned and that any instructions for administration are included. Interim in-house adult protection awareness training should be provided for all staff until such time as full adult protection training is available The use of colour, pictorial signs and other information would improve identification and orientation, particularly in the corridors, for residents with dementia. Recommend roller or steam press to ensure no creases in bed sheets particularly where residents have poor skin quality. Recommend individual baskets for residents’ clean laundry It is recommended that bath thermometers be provided for staff to check water temperatures when bathing residents 2 3. 4 5 6 7 OP9 OP18 OP19 OP26 OP26 OP38 Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR 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 Hawthorne House DS0000036220.V325076.R01.S.doc Version 5.2 Page 32 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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