Inspection on 03/02/06 for Hawthorns

This inspection was carried out on 3rd February 2006.

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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hawthorns 05/07/07

Hawthorns 15/01/07

Hawthorns 14/06/06

Hawthorns 23/05/05

Hawthorns 02/09/04

Hawthorns 06/05/04

Hawthorns 13/10/03

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

CARE HOME ADULTS 18-65 Maytrees 2 Bushey Ground, Brize Norton Road Minster Lovell Witney Oxfordshire OX29 0SW Lead Inspector Lilian Mackay 2nd Inspector Sandra Lemon Unannounced Inspection 3rd February 2006 08.30a Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 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 Maytrees DS0000028948.V278464.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 Adults 18-65. 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. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Maytrees Address 2 Bushey Ground, Brize Norton Road Minster Lovell Witney Oxfordshire OX29 0SW 01993 776336 01993 709056 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) Meriden Homes Limited Miss Jacqueline Godwin Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd May 2005 Brief Description of the Service: The home is registered to provide care for up to six adults under 65 with a learning disability. The needs of residents have been described as mild to moderate learning disabilities and autistic spectrum disorder. The home is not registered to admit those requiring care mainly because of their physical disablement, dementia or mental disorder but strives to continue to care for those who become so, as long as it can continue to meet their needs. The home was considering the special needs of one client who has developed a dementia at this time. Residents’ mental health needs are secondary to their learning disability and these are met by the community mental health services. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspectors undertook this unannounced inspection on a Friday between 08.30 and 13.00 hours. The purpose of this inspection was to see how the home is meeting the National Minimum Standards for care homes for adults 18-65. The inspectors spoke with the residents and the four members of staff on duty, examined staff and residents’ files, the staff rota and the fire log. The home was in need of substantial refurbishment at this time. It provides adequate space both inside and out for residents. One staff member said, ”I enjoy working for Meriden Homes. Every day is different. You don’t know what you’re going to get.” The inspectors would like to thank the residents and staff for their assistance, hospitality and courtesy during this inspection. What the service does well: What has improved since the last inspection? Residents’ access to their personal files has been risk assessed to ensure these are kept securely. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 6 The complaints procedure has been amended and is now compliant with the Regulations. A consistent approach is given when residents seek physical affection. Applicants are now asked to declare any cautions received in their application forms. A risk assessment has been carried out to ensure residents’ records are kept securely. 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. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Residents’ needs are assessed prior to their admission. EVIDENCE: Full professional assessments of residents were seen. The home also carries out its own care needs assessments. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,9. The home provides a service tailored to the individual needs identified in personal care plans [PCPs]. Standard 7 was assessed at the last inspection. No restraint was required at this time. Residents’ independence is promoted by an effective risk assessment system. EVIDENCE: The PCPs seen reflected residents’ social needs well and gave staff clear guidance for responding to behaviours. Evidence was seen that these are reviewed three monthly, exceeding the frequency recommended by the National Minimum Standards. Managers, key workers and residents attend these reviews. Staff work positively with residents to promote their independence. Where residents are experiencing disturbed sleep, sleep charts are used to monitor this. Risk assessments are carried out and reviewed regularly. These should always be dated to identify when review is due. Residents’ access to their personal files has been risk assessed to ensure these are kept securely. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15.16. Residents participate in a range of developmental activities. Residents are involved in local community life. Residents have appropriate personal and family relationships. Residents are encouraged to accept responsibility in their daily lives. Standard 17 was assessed at the last inspection. EVIDENCE: Staff should always record when residents go out or participate in activities in the daily observation sheets. One daily observation sheet seen was noted to have particularly good recording of the social activities undertaken. Evidence was seen that residents are encouraged to pursue their own interests and hobbies. Residents have a TV, video player, music centre and pool table for their use. Residents’ involvement in activities is regularly reviewed. Residents go away on holiday and attend a Saturday Club. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 11 Within the local community residents go to the pub for a drink, visit the fish and chip shop, go out to celebrate birthdays, visit the hairdresser’s, attend college, go to the cinema, go swimming, go into Witney and do personal shopping. Report sheets for recording visitors to the home have not been completed recently. The Regulations require such a record to be kept. Residents have a communal pay phone for making calls. Residents’ personal and social relationships are identified in their PCPs. Staff discourage residents from seeking inappropriate intimacy such as cuddles. Staff recognise the importance of family relationships and make efforts to re-establish contact where this has broken down. Where family relationships exist these are encouraged and residents supported to make home visits. Residents take part in the housekeeping rota to practise domestic skills such as laying tables and washing up. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. The home’s key worker system ensures consistency for residents. Residents’ physical and emotional health needs are met through a range of community-based services. Competent staff administer medication. EVIDENCE: There are currently no handrails in either the bathroom or the shower room. This is acknowledged and consideration is going to be given to the provision of these as one resident is now becoming frailer physically. It is recommended that an occupational therapy assessment be carried out of these areas for this purpose. Community nurses for learning disability, psychiatrists, dieticians, GPs and hospital services are accessed when required. Residents receive visits from the community psychiatric nurse as required. Staff use behaviour charts and one seen showed recent improvements in one resident’s behaviour. The PCPs seen showed that staff are given clear directions about how to respond to individual behaviours and that reactive strategies are devised. Staff were developing residents’ health action plans alongside the community nurse at this time. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 13 No residents were self-medicating. It is recommended that hand written as opposed to typed entries in the medication administration records are signed by the member of staff making the entry, for monitoring purposes. Homely remedies used in the home such as lotions and lozenges should be returned to the pharmacist for destruction immediately they become out of date. A list of the homely remedies used in the home should be compiled and signed approval for the use of these obtained from both the doctor and the pharmacist. Examples of staff signatures and initials are kept to assist in identifying staff responsibilities. Staff have to demonstrate their competence to administer medications, to the pharmacist giving the training before they are designated to do so. Six out of the 11 staff employed by the home are designated to administer medication. Medications are reviewed regularly and records kept of the results of these in a specific file. The possible side effects of medications are highlighted to staff. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22. The complaints procedure is now compliant with the Regulations. Standard 23 will be assessed at the next inspection. EVIDENCE: The complaints procedure has been amended since the last inspection to indicate that the CSCI is the regulating body. It is now compliant with the Regulations. The CSCI have not received any complaints about this service since the last inspection. No residents raised any issues with the inspectors when they spoke to them. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30. The programme of maintenance and renewal needs reviewing to ensure improvements to the environment are made earlier. The home was tidy and fresh smelling at this time. EVIDENCE: The skirting board in the bathroom was coming loose, the dining room walls were marked and in need of redecoration, the lounge ceiling was stained by a recent leak, dining tables were wobbly and had torn table cloths, sharp earth pins under the shower room sink needed boxing in, the coving in the shower room was coming away from the wall, the walls there needed redecoration and the shower cubicle edging needed repair where it was water stained. It was reported that all the communal areas were due for redecoration and that the shower cubicle and the bathroom were due to be refurbished as wet rooms. The areas visited were tidy and fresh smelling. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. Staff receive specific training to meet residents’ needs. Staff recruitment procedures must be improved. Whilst there is a strong commitment to NVQ training, the required ratio has not been achieved within the timescale given. EVIDENCE: Staff work long shifts to ensure there is no break in the activities undertaken with residents. Staff interactions were observed to be positive and sensitive to residents’ needs. Staff were receiving training from the Community Team for Learning Disabilities on crisis intervention. Not all the required documentation as required by the Regulations were available on all staff. For example, two photographs were missing; details of one passport were not available, no references were available for one staff member and only one for another. For the latter a reference from a family friend was accepted. Two staff were employed before their Criminal Records Bureau (CRB) checks came back and evidence was not seen that Protection of Vulnerable Adults (POVA) First checks were undertaken. Staff confirmed that both these staff members without CRBs are subject to supervisory arrangements and that they are not left to work unsupervised. Management staff do their supervisions. Concerns about the home’s recruitment practices Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 17 were highlighted in the last inspection report and no improvement has been noted. Although five of the 11 staff employed are doing NVQs and the manager and the deputy manager are doing the Registered Managers Award the home has not met the standard of 50 of care staff to achieve a care NVQ 2 by 2005. Both the manager and the deputy manager are NVQ assessors. Care is currently provided to residents with early-onset dementia and with schizoaffective disorders. A requirement to provide training in infection control and mental disorder was made at the last inspection. The former was scheduled to take place in July. The manager is asked to supply written evidence that such training took place before this requirement can be deleted. Discussion with staff confirmed that core training is also undertaken and that they are supervised frequently and records of these supervisions maintained. Nine of the 11 staff employed at this time are qualified first aiders. Staff meet with the multi-disciplinary team every two months. All staff attended recent training on quality and diversity and some staff did control and restraint and breakaway training. Speaking of such training one staff member said,” It opened our eyes that training. We didn’t enjoy it. Staff interactions with residents were seen to be positive. A good level of friendly banter was heard and residents appeared comfortable with staff. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,41,42. The manager and the deputy manager are undergoing appropriate training. Standard 39 will be assessed at the next inspection. For the most part the home’s record keeping and policies and procedures safeguard residents. Residents’ health, safety and welfare are safeguarded. EVIDENCE: The roster seen appeared at first to indicate that the home was understaffed on three occasions because the member of staff filling in for absent staff was not entered on the roster. To comply with the Regulations an accurate record of the roster staff actually worked must be kept. Most of the recording in the fire log was good and showed evidence of frequent and meticulous attention to fire safety. The two exceptions to this were that it contained no Employee Register and Training Record so the adequacy of fire Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 19 training for staff could not be assessed and no record was seen of fire drills. 44 out of the 47 recommended policies and procedures were reviewed within the previous three years. This is commendable given the small size of the organisation. It is recommended that all policies and procedures be reviewed within this timescale. Staff are commended for replacing the communal Communication Book with individual ones for residents, thereby giving them more privacy. Good records were seen of accidents to residents. Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X X X 2 3 X Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 21 Yes Are there any outstanding requirements from the last inspection? 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 YA15 YA20 Regulation 17[2] 13[2] Requirement Keep a record of visitors to the home. Staff to sign handwriiten entries in the medication administration records. Return medications to the pharmacist for destruction immediately they become out of date. Make a list of the homely remedies used and have this signed and approved by both the doctor and the pharmacist. Keep all the documentation on staff required by the Regulations. Outstanding requirement from the last inspection. [Original timescale 31/08/05] Provide training in infection control and mental disorder. Outstanding requirement from the last inspection. [Original timescale 31/10/05] Keep an accurate record of the roster staff actually worked. Timescale for action 03/02/06 30/04/06 3 YA34 19 03/02/06 4 YA35 18[1][c] 31/10/05 5 YA37 17[2] 03/02/06 Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 22 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 Refer to Standard YA12 YA18 YA24 Good Practice Recommendations Always record when residents go out or participate in activities on daily observation sheets. Request an occupational therapy assessment of the areas identified. Make good the following - the loose skirting board in the bathroom, the marked dining room walls, the stain on the lounge ceiling, wobbly dining tables, torn table cloths, boxin sharp earth pins under the shower room sink, the loose coving in the shower room, redecorate the shower room walls and the shower cubicle edging. The programme of maintenance and renewal needs reviewing to ensure improvements to the environment are made earlier. Ensure at least 50 of care staff are trained to at least NVQ level 2 or equivalent. Review all policies and procedures within three years. 4 5 6 YA24 YA35 YA41 Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South, Cowley Oxford OX4 2SU 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 Maytrees DS0000028948.V278464.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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