Inspection on 23/06/06 for Holly Tree Lodge

This inspection was carried out on 23rd June 2006.

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 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 23rd June 2006 09:25 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.V288214.R01.S.doc Version 5.1 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.V288214.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hawthorne House Address Sceptone Grove Shafton Barnsley South Yorkshire S72 8NP 01226 712 399 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) None Prime Care 4 You Limited Vacant Care Home 37 Category(ies) of Dementia - over 65 years of age (37) registration, with number of places Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 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. 21st July 2005 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 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. The weekly fee was £344. Hairdressing, toiletries and personal items were not included in the weekly fee and were charged separately. The deputy manager supplied this information during the site visit on 23rd June 2006. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection and comprised information already received from or about the home and a site visit. A Pre-Inspection Questionnaire was sent to the home in April but was not returned to the Commission for Social Care Inspection. The site visit was from 9.25 am to 5.10 pm on 23rd June and from 2.20 pm to 3.30 pm on 26th June 2006. The deputy manager provided assistance, as there was no manager in post. The owner, Mr. Bashir was out of the country. Two residents were tracked throughout the inspection. All residents were seen and two were chatted to during the site visit. Two members of staff were interviewed. No relatives visited during the site visits but five were contacted by telephone and asked for their views of the home. Two social workers were also contacted for their views. Comment cards were sent to ten residents, but none were completed and returned. 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 deputy manager, staff, residents, relatives and the social workers for their assistance and co-operation. What the service does well: What has improved since the last inspection? Staffing levels ensured that residents’ needs could be met, and a social worker commented that the home was “Well staffed”. Service users preferences regarding funeral arrangements had been recorded on their care plans. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 6 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 DS0000036220.V288214.R01.S.doc Version 5.1 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.V288214.R01.S.doc Version 5.1 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 the following standard(s): 1, 3 and 6 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service The home does not provide intermediate care. Prospective residents did not have sufficient information about the home to enable them to make an informed choice about where to live. Residents only moved into the home after their needs had been assessed and been assured that the home could meet their needs. EVIDENCE: The deputy manager said that the acting manager had visited prospective residents to assess their needs to ensure that the home could meet their needs. Copies of the assessments were seen on residents’ files. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 9 Generally, it was residents’ families who chose the home and the main reasons given for choosing this home were that the home was “Homely”, “Best atmosphere” and “Near to family”. Relatives said that they had looked around the home and their questions had been answered. None of the relatives could recall being given a copy of the Service User Guide or any written information about the home. There were no copies of the inspection report, service user guide and statement of purpose on display. The deputy manager was advised to display these and provide more information to prospective residents and their relatives. Copies of the inspection reports were then put in the entrance foyer as an interim measure. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 and 11 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service. Some of the residents’ health, personal and social care needs were set out in individual care plans, but there was not enough detail on how this should be implemented and their changing needs were not reflected in their care plans. Residents’ health care needs were, in the main, met. Medication procedures ensured that residents were protected. Residents’ privacy and dignity was, in the main, respected. EVIDENCE: A resident and residents’ relatives said that residents’ care and health needs were met and relatives were kept informed. Visitors said that they were satisfied with the care provided to their relatives and that staff were helpful. Two care plans were checked and these provided some information of individual care needs but did not provide sufficient details of how these needs were to be met. The daily records could not be linked to the care plans. There was no separate record kept of visits by health professionals. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 11 The deputy manager said that health visits were recorded in the main body of the care notes. However, it was difficult to find which health professional had been involved with a resident and when. The need for clear records was discussed with the deputy manager. There was no evidence that care plans had been reviewed over the last few months. Residents’ weights had not been monitored for the last few months. The deputy manager said that there were problems with the weighing scales but no action had been taken to rectify them. Some risk assessments were out of date and some were missing altogether. There were no activities sheets on files. Inventories of clothing and personal items, where available, were out of date. Records of accidents/falls were kept on residents’ files, but there was insufficient information of how residents were monitored. This was discussed with the deputy manager. The recording and storage of medication was checked on a sample basis. The medication tallied with the Medication Administration Record. Controlled medication was recorded correctly. Temperature records were kept of the medication refrigerator. All medication was stored safely. The administration of medication was observed and the correct procedure was adhered to. Residents and relatives said “Yes” residents were treated with respect and dignity by staff. One relative said, “They’re good”. However, observations and discussion showed that there were areas that could be improved. All residents were considered incapable of using door keys to their bedrooms because of the nature of their illness but there were no risk assessments as evidence of this. There were no lockable facilities within bedrooms, again, because everyone was considered incapable, but no assessments had been carried out. During lunch, three staff including the Senior Carer were feeding two residents at once (i.e. six residents), whilst another member of staff was putting drinks out. The Senior Carer said the reason for this was that there were too many residents who needed assistance. The need to organise a better routine at lunchtime to promote individuality and respect for the residents was discussed with the deputy manager. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 12 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 the following standard(s): 12, 13, 14 and 15 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the 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. They had some choice and control over their lives. A menu did not provide sufficient choice. EVIDENCE: The majority of residents spent the day sitting in the lounge and some were asleep. Two residents chose to walk around the home. There were no activities taking place. The deputy manager said that they had an activities co-ordinator but she was on maternity leave and no one else had taken over this role. One resident who was quite chatty exchanged banter with the staff but other residents were not engaged, inspired or motivated. Residents were not taken out into the local community. When relatives were asked about activities, most said that there weren’t any but tried to qualify this by saying that they didn’t think that their relative could take part anyway. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 13 Dietary needs were catered for. One relative said “…gets nails done and they pamper her” whilst another relative said “She’s bored, bored, bored. Needs something to keep her mind active. It makes it a long day for them.” Relatives said that staff were good at contacting them if they had any concerns about the residents. Those spoken to said that they visited quite regularly but avoided visiting at meal times if possible. One relative said that they were always made welcome and commented “I’m always offered a cup of tea and a biscuit when I come”. Residents could get up and go to bed when they wanted but did not have the freedom to go back to their rooms when they wanted and no risk assessments have been carried out to explain the reasons. Some relatives said that they could not give an opinion of the food as they were never there during mealtimes, but they considered that food preferences had been taken into consideration. Comments were “Yes, been very good, asked me about foods that would tempt (name) to eat”, “Yes, they asked”. One relative said, “They’re better fed than what we are”. The cook had a list of residents who were on special diets i.e. low fat, diabetic, soft. There was a menu board in the dining room but this had been left blank, so residents were not aware of the meals on offer. A copy of the menus was seen and this showed that breakfast was the same every day with no variety and the only cooked option was eggs. There was no choice at the lunchtime meal. One of the evening meals, as written, was insubstantial. The need to provide more variety and choice was discussed with the deputy manager. During the second day of the site visit, the cook demonstrated that she had already commenced updating the menus to provide greater choice. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 14 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 the following standard(s): 16 and 18 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service Relatives were confident that their complaints would be taken seriously. Residents were not fully protected from abuse. EVIDENCE: Residents’ relatives knew the deputy manager and some of the long-term staff and said that they would tell them if they had concerns or complaints. One relative said that she would complain direct to the owner, Mr. Bashir. They were confident that complaints would be dealt with. The complaints procedure was displayed in the entrance foyer. The home’s complaint record was seen. No complaints were recorded since the last inspection and no complaints had been received by the CSCI. There were no allegations of abuse. According to the deputy manager, staff had received some adult protection training but there was no certificates or documentation to prove this. The deputy manager was not aware of the correct procedure for dealing with allegations of abuse. The home had an adult protection procedure but this did not provide sufficient details of who to contact in the event of an allegation of abuse. This was discussed during the site visit. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 15 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 the following standard(s): 19 and 26 Quality in this outcome area is adequate. This judgement has been made from evidence gathered before, during and after the visit to this service. The home was clean and hygienic but improvements could be made to the environment. EVIDENCE: The home was welcoming and there were no offensive odours. Relatives said, they thought the home was clean and commented on the continuous cleaning that went on. Bedrooms were considered to be “Lovely”, “Brilliant” and “Comfortable”. Comments about the general environment and communal facilities were “Fine” and “Alright”. One relative felt that “The décor could be better” and went on to talk about the scuffed paintwork and said “Its layer on layer of paint – needs taking back to bare wood and repainting – it would be better”. Another comment was about the first floor of the home and how it was “much better” than the ground floor. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 16 A social worker commented on the unusual layout of the home; because of the need to go through the dining room to get to other parts of the home. A check of the environment included the bathrooms and lavatories, which looked dull, drab and unwelcoming. The flooring in the majority of lavatories was stained, damaged and unappealing. A recommendation to refurbish the lavatory floors had not been addressed. Some of the bed linen and towels were looking old, worn and ragged. An audit of all bed linen and towels was needed to determine the quality and quantity. All corridors looked the same and it took time to get one’s bearings. Therefore residents with dementia would find the corridors disorientating The deputy manager was advised on how the environment (particularly corridors and doors to toilets and bedrooms) could be improved to assist people with dementia. The home had an enclosed garden leading from the lounge. The garden surface was uneven and unkempt and therefore not safe or suitable for the residents. Mobility aids and equipment, i.e. wall bars, raised toilet seats, support rails, were provided to enable residents to maintain their independence. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 17 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service. The staffing levels met residents’ needs, but the skill mix needed improving. The home’s recruitment practices had lapsed therefore residents were not supported and protected. Staff were not trained to do their jobs. EVIDENCE: Staff files that had been compiled by the acting manager contained the required recruitment information i.e. employment histories, two references, identification documents and Criminal Records Bureau disclosures. However, since the acting manager had left, the recruitment procedure had lapsed and one file for a recent employee did not contain the required information. There was no information on any of the staff files seen during the site visit to demonstrate that that staff had received any induction training, and only the deputy manager and a carer had National Vocational Qualifications in care. This meant that none of the senior carers had this qualification. According to the deputy manager, three members of staff were currently undertaking NVQ Level 2 and two more were due to commence. To attain the minimum of 50 of staff with NVQ qualification, more staff needed to undertake this training. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 18 Relatives spoke positively about the staff’s attitude and care practices. Comments were “One is brilliant with my mum”, “They think a lot about her”, “Couldn’t wish for a better load of girls there” and “They’re good”. There were sufficient numbers of staff on duty during the site visit. that staffing levels had improved. Staff said There was no ongoing staff training. Some staff were said to have undertaken some training but there were no certificates or documentation as proof. The deputy manager said that there were plans for some of the staff to attend some training courses. There was no evidence that staff had received any training in the care of people with dementia. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34, 35 and 38 Quality in this outcome area is poor. This judgement has been made from evidence gathered before, during and after the visit to this service. The home had no registered manager or acting 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: There had been no registered manager since August 2003. A series of acting managers had been in post but the last one left in April 2006. The deputy manager was overseeing the home until a manager commenced. The deputy manager said that a manager had been appointed and was due to commence shortly. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 20 The home had a Repairs and Maintenance Book that was used by the handyman. The home had no auditing system for quality assurance purposes for the environment or for procedures or work practices within the home. Relatives said there were no meetings for residents and relatives and they had not completed surveys/questionnaires related to their views of the home. Staff supervisions were not taking place and there were no records of staff meetings. The owner did not produce reports of his visits to the home as required by Regulation 26 of the Care Standards Regulations. The insurance certificate on display was out of date. The Pre-inspection Questionnaire sent in April 2006 was not returned to the Commission for Social Care Inspection, and could not be found during the site visit. The CSCI issued a second copy for completion. Relatives said that they left small amounts of money with the home for hairdressing and incidentals and were always issued with receipts. Money held on behalf of residents was stored safely. The money held on behalf of the two tracked residents plus two residents chosen at random was checked against the records. Cash was held separately for each resident and the amounts were correct. Receipts were available for purchases made on behalf of residents. A previous recommendation that two staff should check service users finances on a monthly basis had not been implemented. Staff were not up to date with their mandatory health and safety training (e.g. infection control, fire awareness, moving and handling, first aid, basic food hygiene). A member of staff who was undertaking NVQ Level 2 said that she had covered some of this mandatory training as part of her course. However, the home’s records were not up to date and there was no information to support this. A previous requirement for First Aid training for all staff left in charge of the home (i.e. Senior Carers) had not been met. Fire drills were not held regularly and there were no records relating to fire drills. The deputy manager was not aware of the need for checklists and resident information in the event of a fire. This was discussed during the site visit. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 21 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 X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 2 9 3 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 X X X X X 3 STAFFING Standard No Score 27 3 28 1 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 1 X 1 2 3 X X 1 Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 22 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 2 Standard OP1 OP7 Regulation 5 15 Timescale for action The Service User Guide must be 18/08/06 available for anyone who wishes to see it. Care Plans and Daily Care 18/08/06 Records must be more detailed to reflect the care needs of service users. (Requirement outstanding from or before June 2005) Care plans must be reviewed at 18/08/06 least once per month to ensure that residents’ care and health needs are met. All residents’ care plans must 15/09/06 include up to date detailed inventories of clothing and personal property. All residents’ care plans must 18/08/06 include risk assessments for falls with full and up to date information All residents’ care plans must 18/08/06 include risk assessments for moving and handling with full and up to date information. All residents care plans must 15/09/06 include risk assessments for restraints on freedom of movement e.g. bedroom door DS0000036220.V288214.R01.S.doc Version 5.1 Page 23 Requirement 3 OP7 15 4 OP7 12 5 OP7 13 6 OP7 13 7 OP7 12 13 Hawthorne House 8 OP7 13 9 10 OP7 OP8 12 12,13 11 OP8 12 12 OP10 12 13 OP10 12 14 OP12 16 15 OP12 16 16 17 18 OP15 OP15 OP18 12 12 13 19 OP18 13 keys. Where restraints are deemed to be necessary e.g. bed rails, risk assessments for the resident’s health and safety must be fully recorded. Nutritional risk assessments must be reviewed and updated at regular intervals. Records of healthcare visits to service users must be implemented and maintained (Requirement outstanding from or before June 2005). All residents must be weighed and monitored regularly to ensure that their health needs are met. Residents’ rights to be treated as individuals must be respected at all times, including when being given assistance at meal times. Residents’ rights to be treated as individuals with the right to privacy must be respected, including the use of a lockable facility, subject to risk assessment. A consistent programme of activities, suited to residents’ needs must be provided. (Requirement outstanding since August 2005) Residents must be given opportunities for stimulation through individual leisure and recreational activities both inside and outside the home. Menus must provide more variety and choice at all meals. Residents must be informed of meals and the available options All staff must undertake adult protection training. (Outstanding requirement from or before November 2004) Staff left in charge of the home DS0000036220.V288214.R01.S.doc 18/08/06 18/08/06 18/08/06 15/09/06 23/06/06 18/08/06 18/08/06 15/09/06 18/08/06 18/08/06 15/09/06 18/08/06 Page 24 Hawthorne House Version 5.1 20 21 22 23 24 OP19 OP19 OP19 OP28 OP29 23 16 23 18 19 25 OP30 18 26 OP30 18 27 28 OP31 OP31 8 10 29 OP33 24 must be made aware of the correct procedure for reporting allegations of abuse. The stained and damaged flooring in lavatories must be refurbished. Bed linen and towels must be audited and replaced as necessary. The garden surface must be levelled, and made safe and suitable for residents. A minimum of 50 of care staff must be trained to NVQ Level 2 in care. All staff must be deemed fit to work at the home, by the provision of CRB disclosures at the correct level and prior to employment, a record of the employee’s full employment history, authenticated references, proof of identity, a recent photograph and evidence that discrepancies have been discussed Staff must undertake structured induction training to General Social Care Council specifications within six weeks of employment. Staff must receive training appropriate to their work to ensure that they are up to date with current practices, e.g. dementia training. Mr. Bashir must appoint a manager to manage the home Mr. Bashir must make an application 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 DS0000036220.V288214.R01.S.doc 15/09/06 18/08/06 15/09/06 15/09/06 18/08/06 18/08/06 15/09/06 18/08/06 15/09/06 18/08/06 Hawthorne House Version 5.1 Page 25 30 OP33 26 31 32 OP34 OP38 25 13 33 OP38 13 34 35 OP38 OP38 23 23 36 OP38 23 37 OP38 23 environment, services and systems used within the home. Mr Bashir must visit the home and produce a written report each month as required by Regulation 26 of the Care Home Regulations. A copy of the monthly report must be sent to the CSCI. An up to date insurance certificate must be displayed at all times. All mandatory health and safety training, including moving and handling, infection control, basic food hygiene, and emergency first aid, must be up to date for all care staff. Persons left in charge of the home on each shift, i.e. senior carers, must undertake First Aid at Work training. (Outstanding requirement from September 2005) Fire drills must be held regularly to ensure that all staff are fully conversant with the procedure. Staff left in charge of the home must be fully aware of their responsibilities in the event of a fire to ensure the health and safety of residents. A record must be kept of every fire practice, drill or test of fire equipment (including fire alarm equipment) All staff must receive fire awareness training twice per year. (Outstanding requirement from July 2005) 18/08/06 23/06/06 15/09/06 15/09/06 18/08/06 18/08/06 23/06/06 15/09/06 Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 26 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 Refer to Standard OP1 OP19 OP19 OP35 Good Practice Recommendations Copies of the Service User Guide should be issued to all prospective residents or their relatives to ensure that they can make an informed choice. Bathrooms and lavatories should be domestic in character to provide pleasant surrounding for residents. The use of colour, pictorial signs and other information would improve identification and orientation, particularly in the corridors, for residents with dementia. A monthly audit of residents’ personal allowances by two members of staff would help safeguard residents’ finances and also the member of dealing with residents’ finances. Hawthorne House DS0000036220.V288214.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Sheffield Area Office 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 DS0000036220.V288214.R01.S.doc Version 5.1 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!