Inspection on 03/07/07 for Holly Tree Lodge

This inspection was carried out on 3rd July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector 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 22/01/07

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 Michael O`Neil Key Unannounced Inspection 3rd July 2007 09:10 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.V337806.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.V337806.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 cdawber@redrosecare.co.uk 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.V337806.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. 22nd January 2007 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 manager confirmed that the weekly fee from 3rd July 2007 was £363.50. Additional charges included hairdressing and private chiropody. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection carried out by Mike O’Neil, regulation inspector. This site visit took place between the hours of 9.10 am and 16:35 pm. Lynne George, manager, awaiting registration with the CSCI, and Sheila Goodison, area manager of the company were present during the inspection. The manager submitted a pre inspection questionnaire to the CSCI prior to the actual visit to the home. Some information from the questionnaire is included in the main body of the report. The CSCI sent out questionnaires asking health professionals, residents, relatives and staff about the care and the service provided. There was a reasonable response and the CSCI received 1 health professional, 1 staff and 4 resident/relative questionnaires back. Opportunity was taken to make a partial tour of the premises, inspect a sample of care records, check records relating to the running of the home, check the homes policies and procedures and talk to 4 staff, 1 visiting Health Professional, 2 relatives and 4 residents. The inspector wishes to thank the staff, relatives and residents for their time, friendliness and co-operation throughout the inspection process. A copy of the previous inspection report was displayed and available in the foyer of the home. Information about how to raise any issues of concern or make a complaint was on display in the foyer. What the service does well: Staff interviewed showed a good knowledge of the residents health and social needs. Health care professionals said that the standard of care delivered at the home was good. Residents said that the care they were receiving was good. Relatives made comments such as “the staff are caring” and “the care at Hawthorne House is very good ”. The inspector saw staff consistently treating residents in respectful and friendly way. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 6 Residents said that they had a choice of food and that the quality of food served was good. Relatives and residents said the home was always kept clean. Residents, staff and relatives said that they met regularly with the manager of the home and spoke positively about her approachability and helpfulness. What has improved since the last inspection? What they could do better: Some care plans and resident assessments must be improved to ensure that staff are able to know what to do for each resident. Group and individual activities suited to residents needs would provide stimulation and motivation. There was not enough information displayed in the home that may help residents with orientation. Staff must undertake adult protection training so that residents have more protection from the risk of abuse. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 7 Refurbishment of the home must continue so that all areas of the home used by residents are well maintained. Staff must receive induction training so they have the required skills to meet the residents’ needs. Staff need to undertake moving and handling and fire safety training so that the health and welfare of residents can be protected. Procedures need to be improved so that residents’ finances are fully safeguarded. 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.V337806.R01.S.doc Version 5.2 Page 8 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.V337806.R01.S.doc Version 5.2 Page 9 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): Standards 1,2 and 3.Standard 6 is not applicable to this home. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Prospective residents had some of the information, in the Statement of Purpose and their contracts, to enable them to make an informed choice about where to live. Assessments were carried out for residents but not enough information was included in the assessment. This meant that staff might not be aware of all the residents needs to ensure that they could be met. EVIDENCE: 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. However, the Statement of Purpose still needs expanding and Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 10 updating to provide more specific details about the staffing and management of Hawthorne House. Since the last inspection the company had incorporated the Service User guide into the Statement of Purpose. This will help enable prospective residents to make an informed choice about where to live. The manager said that all residents or their advocates had now been provided with a contract covering the terms and conditions of the home. However not all advocates had returned a signed copy of the contract. The manager confirmed that the contracts contained all the information required by the Regulations. This will provide residents and their relatives with information about the fees charged and what the fees are for. Three care plans were checked and these contained assessments of the residents needs. The assessments were in varying formats. The most recent assessment seen was not adequate, however, because the assessing member of staff had used only a tick box to identify the basic needs of the resident. A more detailed assessment is required. Some information from the assessment had been formulated into a plan of care for the resident. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 11 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): Standards 7, 8, 9 and 10. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The residents’ health, social and personal care needs were generally well documented in the care plans; however, inadequacies in the documentation in two care plans meant that the resident’s needs could not be fully met. A range of health care professionals visited the home to assist in maintaining the health care needs of residents. Relatives said that the staff were helpful, friendly and nice and provided a good standard of care. Residents said they were happy at the home and the care they received. Medication storage protected the residents’ health and welfare. Medication procedures did not fully protect the residents’ health and welfare. Residents’ privacy and dignity was respected. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 12 EVIDENCE: Three resident plans of care were checked. The standard of the care plans had improved significantly since the last inspection and the staff had clearly made an effort to meet the requirements made at the last inspection. Two care plans however did not provide enough detail of the residents specialist needs. Staff had failed in one care plan to record the interventions required for a resident who was at a very high risk of developing pressure sores. Information such as, caring for the resident on a specialist mattress and regularly changing the resident’s position etc needed to be recorded. It was noted however that staff had been recording on the daily notes for the last week that they had been changing the resident’s position every two hours. The inadequacies in another care plan checked again related to a resident’s pressure area problem. Staff had only produced a care plan identifying that pressure area care should be provided during the night. The resident clearly needed 24-hour pressure area care. As highlighted earlier however there had been an improvement in the care planning documentation. The care plans identified that a range of health professionals visited the home to assist in maintaining the residents health care needs. There was evidence to suggest that the resident or their relatives were involved in the drawing up or the reviewing of the care plans and relatives interviewed said that they were kept informed of their relatives (residents) condition. Accidents were recorded in the accident book. Evidence was also seen that the manager was now monitoring the number of accidents to determine the residents most at risk, causes of accidents and whether any patterns were formed. Health care professionals said that, more recently, staff at the home communicated well with them and felt that the standard of care delivered at the home was good. Staff interviewed showed a good knowledge of the residents health and social needs. Residents said that the care they were receiving was good. Residents consistently added comments such as ” the staff are nice, friendly and helpful”. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 13 Relatives made comments such as “the staff are caring” and “the care at Hawthorne House is very good ”. One relative said that they had no worries when they left their relative (resident) after visiting them because they knew they would be well cared for. Some residents were not able to say whether they felt that they were being well cared for; these residents were well dressed in clean, age appropriate clothing and attention had been paid to hair and nail care. Medicines were securely stored around the home in locked cupboards. Medicine Administration Records (MAR) checked were completed with staffs’ signatures. The procedure for booking in medication now included the date of receipt of the medication. Handwritten entries for medications prescribed in-between monthly deliveries appeared to accurately reflect prescription information but had not been signed by the person making the entry, or countersigned by a witness, to show they had been checked and confirmed as accurate. Staff said they had received medication training. The inspector saw certificates of this training. All the residents and relatives spoken with said that the staff were respectful and friendly. The inspector saw staff consistently treating residents in a respectful and friendly way. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 14 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): Standards 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Residents were able to make some choices about daily living and being involved in social activities. Some activities were offered to residents. To improve choices and maintain interests, activities need to be more individualised to the residents assessed needs and preferences. The home had an open visiting policy, which assisted in maintaining good relationships with residents’ representatives. Meals served at the home were of a good quality and offered choice. EVIDENCE: Residents said they were able to get up and go to bed when they chose, and were seen to walk freely around the home, if able. Relatives spoken to said they were able to visit at any time and were made to feel welcome. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 15 Throughout the day friends and family were seen visiting the home and there seemed to be a very friendly and welcoming feel in Hawthorne House. Visitors knew the majority of the residents and visa versa, which meant that residents were communicating with visitors even if they were not related. The inspector saw that three particular residents received little or no staff interaction or stimulation for much of the day. On three separate occasions during the day the inspector saw the residents in a separate lounge and they were always asleep. Some activities were occurring during the afternoon but this only involved a few residents. Staff were trying to provide a more stimulating environment for the residents. The manager was able to provide information showing forthcoming trips to the coast and entertainers who were due to visit the home. A more individualised activity programme is needed which should encompass the likes and dislikes of the residents, this information could be discussed with relatives. This would enable residents’ opportunity to exercise their choice in relation to social and leisure activities. There was not enough information displayed in the home that may help residents with orientation. The larger lounge/dining room only had one small dark faced clock on display and some residents’ bedrooms did not have the residents name on the door. There was a notice board with the date and menu for the day written on it. However displaying information such as the weather, the place where the residents were living or a news item, may help the residents with orientation to time and place. Residents said that they had a choice of food and that the quality of food served was good. Staff served lunch in an unhurried manner and the atmosphere in the dining room was very pleasant. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 16 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): Standards 16 and 18. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Complaints procedures are in place to enable residents and relatives to feel confident that any concerns they voice will be listened to. Staff had some understanding of the procedures to be followed should they suspect any abuse at the home. However staff need more training to help ensure that residents are protected from abuse. EVIDENCE: Complaints procedures were displayed in the home. Residents and relatives said that if they had any concerns that they would feel comfortable in talking to the manager and they knew that the problems would be dealt with immediately. Staff said they had received information on adult abuse but had not received any formal training. The adult protection policies and procedures were available at the home and had been condensed into one file. Hawthorne House DS0000036220.V337806.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): Standards 19, 21, 24 and 26. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The homes environment has continued to improve. However, not all of the homes environment was well maintained which meant that not all residents lived in a comfortable environment. EVIDENCE: Progress has continued to totally refurbish the home. There were no offensive odours. Relatives and residents said the home was always kept clean. The lounge and dining room had been redecorated; refurnished, re-carpeted and new light fixtures were fitted. This refurbishment was continuing Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 18 throughout the home and bedrooms were being refurbished on a rolling programme. New fire and nurse call systems have also been installed in the home. The home was tidy and uncluttered and 8 requirements relating to the environment made at the last inspection had been addressed. The gardens are overgrown in parts and access needs to be improved so that residents can enjoy the gardens in a safe way. Some window frames still need replacing. Bedrooms checked were comfortable and homely. Residents said their beds were comfortable. Bed linen checked was clean although some is becoming a little worn and will need replacing soon. Window restrictors were fitted to all windows checked. The hot water temperature in one bathroom checked measured a safe temperature below 45 degrees centigrade. This will assist in maintaining resident safety. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 19 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): Standards 27, 28, 29 and 30. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were not employed in sufficient numbers to meet the residents needs. A proportion of staff undertook NVQ training. The recruitment information obtained for new staff was sufficient to adequately protect the welfare of residents who lived at the home. Staff were not receiving adequate training on their induction, so may not have the required skills to meet the residents needs. EVIDENCE: The staff rota identified agreed staffing levels had not been met on the morning of the inspection and on the previous day. There was a shortfall of one care assistant on the morning. This shortfall would have some negative affect on areas such as providing social stimulation to residents. Staff did say that generally adequate staffing levels are maintained at the home. Relatives said that staff were very visible around the home when they visited. The required 50 of care staff had not achieved their level 2/3 NVQ qualifications, although the manager said a number of staff were undertaking Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 20 their NVQ training. Two members of staff interviewed said they had completed their NVQ training. The recruitment records of 2 recently employed staff members were checked. The staff had provided employment histories and the home had obtained two written references for each of them. These were satisfactory. Protection Of Vulnerable Adults (POVA) checks had been made. Enhanced Criminal Record Bureau (CRB) checks had been obtained for the staff members. Previous requirements from the last inspection had been met. There was a training and development plan for the staff. Staff said they were being encouraged to attend more training on various care topics and that they were enjoying a course on Dementia Care at the moment. Two staff files checked identified that the staff had not received any induction training when they commenced work at Hawthorne House. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 21 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): Standards 31, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. There was a positive style of management in the home. This would have a positive affect on the quality of the service the residents receive. Some of the homes financial procedures did not fully promote the welfare of the residents. Staff were not being adequately supervised, so they may not have the required skills to meet the residents needs. Some of the homes procedures did not fully promote the health, safety and welfare of residents and staff. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 22 EVIDENCE: The care manager is experienced in the care of older people and has achieved her NVQ level 4 award. The manager started in post in April 2007. The manager said she had returned her manager application to the CSCI. The manager was very positive about the inspection process and was committed to improve the service of Hawthorne House and meet the National Minimum Standards and Care Home Regulations. In the past few months’ good progress had been made to improve the service. Residents, staff and relatives said that they met regularly with the manager of the home and spoke positively about her approachability and helpfulness. The home was developing and implementing an in-depth quality assurance system. There was evidence of internal auditing of the homes environment, services and records. Staff meetings were held and minutes of these meetings were seen. The responsible individual visited the home on a regular basis, a report was written following the visits. The home handles money on behalf of some residents. Account sheets were kept and receipts were seen for all transactions. However, residents’ financial interests were not fully safeguarded because there was no bank statement held at the home to provide evidence that the residents monies had actually been banked and that the monies were accruing interest. Staff said they were not receiving supervision on a regular basis. The manager confirmed that not all of the care staff had received individual management supervision. Staff spoken to had some understanding of the home’s fire procedures. However, the health and welfare of residents could not be fully protected, as two members of staff had not received recent moving and handling training or fire safety training. Practice fire drills had been conducted in the home, however the records did not identify any corrective action needed after the drill and the drills were not conducted at different times of the day. Fire records stated that weekly testing of the fire alarm system had occurred. A sample of records showed servicing of the homes utility systems had occurred. The manager after speaking to the director of the company confirmed that a 5 yearly electrical test had been carried out at the home and that a copy of the certificate would be forwarded to the CSCI once the home received the certificate. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 23 At the time of inspection fire exits were clear and window restraints were in situ at first floor windows checked to prevent falls. Hazardous products were safely stored in the home. This will promote the safety and welfare of the residents. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 24 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 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 3 X X 3 X 3 STAFFING Standard No Score 27 2 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 2 3 X 2 Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 25 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 Provide greater detail of how the home intends to meet the criteria of the Statement of Purpose. (Previous requirement partially met) All residents must be issued with a contract/statement of terms and conditions. (Previous requirement partially met) Assessments must be completed fully to ensure that the home can meet all the needs of the resident. The care plan must set out in detail the action, which staff need to take to meet all aspects of the personal and social care needs of the resident. All handwritten instructions for medication on the MAR sheets must be signed by the person making the entry. A second person must sign to confirm the information is accurate according to the printed label. Residents must have the opportunity to exercise their DS0000036220.V337806.R01.S.doc Timescale for action 01/10/07 2. OP2 5 01/10/07 3. OP3 14 01/09/07 4. OP7 15 01/09/07 5. OP9 13 01/09/07 6. OP12 16 01/10/07 Hawthorne House Version 5.2 Page 26 7. OP12 16 8. 9. OP18 OP19 13 23 10. OP19 23 11. 12. OP19 OP27 23 18 13. 14. OP30 OP35 19 16,17 15. 16. OP38 OP38 23 18 choice in relation to social and leisure activities. (Previous requirement partially met) Arrangements must be implemented to ensure that residents are orientated to date, time and place. All staff must undertake adult protection training. (Previous requirement) All areas of the home used by residents must be well maintained, of sound construction, kept in a good state of repair externally and internally and must be well decorated. Window frames must be audited and replaced or repaired as necessary. (Previous requirement partially met) The garden surface must be made safe and suitable for residents. There must be sufficient numbers of competent and experienced staff on duty at all times. Staff must receive induction training within 6 weeks of appointment to their posts. Increased procedures must be put in place to ensure that residents’ financial interests are safeguarded. Staff must receive fire instruction and/or fire safety training at least twice a year. Staff must receive annual moving and handling training. 01/10/07 01/11/07 01/04/08 01/04/08 01/12/07 01/09/07 01/09/07 01/09/07 01/09/07 01/12/07 Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 27 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. Refer to Standard OP28 OP36 Good Practice Recommendations 50 of care staff should be trained to NVQ level 2 or equivalent. Formal staff supervision should occur at least six times a year. This supervision should be documented. Hawthorne House DS0000036220.V337806.R01.S.doc Version 5.2 Page 28 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.V337806.R01.S.doc Version 5.2 Page 29 - 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!