Inspection on 24/11/05 for The Hawthornes Care Home

This inspection was carried out on 24th November 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Hawthornes Care Home 04/04/07

The Hawthornes Care Home 03/07/06

The Hawthornes Care Home 27/06/05

The Hawthornes Care Home 26/01/05

The Hawthornes Care Home 19/07/04

The Hawthornes Care Home 03/02/04

Similar services:

Snydale Care Home

Abbey The

Larchfield Manor

Hawkhills

Beeches The - North Yorkshire County Council

The Grove Waltham

Carentan House

Ravensworth Lodge

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

CARE HOMES FOR OLDER PEOPLE The Hawthornes Care Home Bradford Road Birkenshaw West Yorkshire BD11 2AN Lead Inspector Stephen French Unannounced Inspection 24th November 2005 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 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. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service The Hawthornes Care Home Address Bradford Road Birkenshaw West Yorkshire BD11 2AN 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) 01924 284200 Tri-Care Limited Mrs Coleen Smith Care Home 40 Category(ies) of Old age, not falling within any other category registration, with number (40) of places The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th June 2005 Brief Description of the Service: The Hawthornes is a care home providing personal care and accommodation for 40 older people. It is owned by Tri-Care Homes Ltd., a private limited company with several other similar homes in the area. The home is situated in North Kirklees on the Bradford boundary. The home was purpose built and opened two years ago. It is built over two floors and there are gardens to two sides of the building and a large car park to the front. It is located on a main bus route. All the service users rooms are single with en-suite facilities. There is a passenger lift and good communal facilities. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection, which took place on the 24th November 2005. This was the second inspection carried out during the inspection year. Not all of the standards were assessed during this inspection. A tour of the home was conducted and a selection of service user and staff files were examined. Requirements and recommendations from the previous inspection were checked for compliance. It was noted that some of these had not been actioned therefore further requirements and recommendations are to be made. The registered manager is currently on long-term sick leave and an acting manager is in place. The inspector feels confident that the acting manager will ensure that shortfalls identified during the inspection will be rectified and systems put into place to monitor their compliance. What the service does well: What has improved since the last inspection? The service users terms and conditions of admission (contract) are now signed by the service user and manager of the home. Records for service users personal monies have improved. There are now frequent service user meetings. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 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. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 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 The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 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): 2 Service users are given a copy of the homes conditions of admission. EVIDENCE: Each service user is given a terms of acceptance document (contract) which they or their representative sign following admission. This document informs the service user about the fees of the home and what is and is not included in these fees. It also outlines the terms and conditions of admission. Following a recommendation from the last inspection these contracts have been signed by both the service user and service provider. Documentation checked confirmed this. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 Although the service users health and personal needs are met, this is not reflected in the care files The standard of administration and the storage of medication is poor and places the service users at risk. EVIDENCE: Three service users care files were examined as part of the inspection. Two care files were seen for service users recently admitted to the home and one file examined was for a service user who had been in the home for a few weeks. One file only contained a pre-admission assessment and although this identified that the service user required support from staff there was no care plan in place and no risk assessments completed. A skin assessment had been made during the initial assessment and identified that the service user was at risk of developing a pressure sore but there was no care plan in place. Another care file examined had risk assessments in place for such things as falls and moving and handling but these had not been completed fully. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 10 Where it has been identified that a service user has complex needs, a care plan must be in place, this must have measurable goals and must inform staff of how these are to be met. Risk assessment must be completed for such things as nutrition and moving and handling. The home must ensure that service users who are admitted to the home have care plans and risk assessments in place within 24 hours of admission. The acting manager is aware of the shortfalls in the care documentation and is currently working towards improving these. Evidence was seen that the staff access members of the multidisciplinary team such as members of the mental health team, district nurses, GP, opticians and dentists. Following the homes last inspection, requirements and recommendations were made surrounding the administration and storage of medication within the home. It was noted that little had changed since the last inspection. The drug cupboard contained a syringe that had what appeared to be medication in it, which was not named. Stock balances of medication checked were incorrect. One service user, who’s medication administration records were checked, had not had their medication for five days. The staff informed the inspector that this was due to the stock running out and the home awaiting the prescription. On checking the stock balance it was noted that there should have been twenty- eight tablets left. The manager checked the stock cupboard and found the service users medication already in stock. It is unacceptable that medication is omitted and the home must ensure that service users’ stocks of medication are always available. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 Appropriate social activities are available to service users should they wish to join in. Service users are able to exercise choice in most things they do within the home. EVIDENCE: Following a recommendation from the last inspection the acting manager is currently putting together a more structured program of social activities. These are advertised on a daily basis and include such things as coffee mornings, Manicures, bingo, film shows and outside entertainers visiting the home. The local junior school are performing their nativity play at the home in December. The manager stated that each service user will have an individual assessment to ensure that they have the opportunity to join in social activities if they wish. Currently it is the care staff that are responsible for arranging social activities and this is dependant upon them having the time to organise these. The provider should consider employing an activities organiser who is responsible for arranging and supervising social activities within the home. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 12 Service users are able to exercise choice in most things they do this includes where they spend their day, their preferred rising and retiring times and choices of food. Since the acting manager has been at the home she has held two resident and relative meetings to involve them in changes within the home. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has an accessible complaints policy. EVIDENCE: The home has a comprehensive complaints policy, which is given to service users on admission. Evidence was seen that the manager investigates all complaints and makes the complainant aware of the outcome of any investigation. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 26 Improvements are required in the laundry to prevent cross infection and ensure fire safety. EVIDENCE: A tour of the home was conducted as part of the inspection and there were no unpleasant odours detected in any part of the home. It was noted that care staff are working in the laundry but have not received adequate training in how to operate the washing machines to ensure the correct temperature is used to prevent cross infection when dealing with infected laundry. The laundry room was dirty and the filters in tumble dryers were full of lint. These had not been cleaned for some time; this is a fire hazard and must be addressed. Minutes of a recently held service users meeting highlighted poorly ironed and missing items of clothing. The registered provider should employ laundry staff that have responsibility for the day-to-day running of the laundry. This will ensure that such things as The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 15 general cleaning and the cleaning of the filters on the tumble dryers are carried out at regular intervals. Following a recommendation from the last inspection, paper towels have been provided in the laundry for staff. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission 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 The home does not employ sufficient domestic and kitchen staff, which could result in the care of the service users being compromised. The home has a robust recruitment policy, which protects the service users from harm. EVIDENCE: Although the home has its full compliment of care staff they do not have sufficient domestic or kitchen staff. Care staff complete domestic and kitchen duties on their day off and also do some basic housekeeping duties as part of their working day. Following a service users meeting concerns were raised about beds not being made, bins not being emptied and general untidiness within the home. This is unacceptable and compromises the care that the service users receive. Requirements have been made in previous inspections surrounding staffing and these have not been actioned. The registered provider must ensure that there are sufficient domestic and kitchen staff employed. Care staff should not be involved in domestic duties when they are supposed to be delivering care to service users. Five care staff have completed an N.V.Q level two qualification and a further member of staff is working towards the award. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 17 Four staff details were checked and these contained the required information, including two written references, one from a previous employer, proof of the employee’s identity and Criminal Records Bureau checks had been undertaken. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 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): 32,35,36 The acting manager ensures that there is an open, positive and inclusive atmosphere within the home. Service users personal monies are kept securely within the home. The manager needs to ensure that staff supervision takes place at least six times per year. EVIDENCE: The registered manager of the home is currently on sick leave. The acting manager has only been in post for a few weeks. She has already made improvements in ensuring that the service users and relatives are kept informed about things within the home. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 19 Service users are able to keep small amounts of personal monies within the home for safekeeping. This enables them to purchase small items such as newspapers sweets and pay for hairdressing. When money is taken out of the service users account they are given a receipt, which is signed by the member of staff handing the money to the service user. It was suggested that the service user also signs the receipt confirming that they have received the money. Three amounts of service users monies were examined and the balances tallied with the records held by the home. Care staff receive formal supervision, which covers amongst other things, care practices and training needs. Four staff files checked confirmed that this does not always take place at regular intervals. The manager was aware of this and is currently trying to catch up with outstanding supervisory sessions for staff. The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X 3 X X X N/a HEALTH AND PERSONAL CARE Standard No Score 7 1 8 3 9 1 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 X 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 x X X X X X X X 1 STAFFING Standard No Score 27 1 28 X 29 3 30 x MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score x 3 x x 3 2 x x The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 21 Are there any outstanding requirements from the last inspection? YES STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP7 Regulation 15(1) Requirement Timescale for action 31/01/06 2 OP9 13(2) 4. OP9 13(2) 5. OP27 18(1)(a) The registered person must prepare a written plan setting out how the needs of service users will be met: Specific outcomes and goals must be set out in the care plan and daily records must evidence how these needs are being met. (outstanding from 31/7/05) The registered person shall make 24/11/05 arrangements for the recording of medication in the home: Controlled drugs should be logged and recorded in the appropriate book, including those service users on respite. (Outstanding from 31/7/05 ) The registered person must 24/11/05 make arrangement for the safekeeping of medicines and account for medication held in the home. ( Outstanding from 31/7/05 ) The service provider must, 31/01/06 having regard to the size of the care home, the statement of purpose number and needs of service users ensure that there are sufficient numbers of staff, DS0000035661.V267174.R01.S.doc Version 5.0 The Hawthornes Care Home Page 22 especially domestic staff, to promote the health and welfare of service users. This is an outstanding requirement from 26/01/05, 31/7/05 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 OP7 OP8 OP12 Good Practice Recommendations Risk assessments should be reviewed on a monthly basis. Baseline assessments for nutrition, tissue viability and mobility need to be completed at the point of admission. It is recommended that each service user has an individual assessment to ensure that they are offered the opportunity to participate in fulfilling activities. Consideration should be given in employing a full time activities co-ordinator. Care staff should not work in the laundry unless they have been trained to do so. The filters in the dryers should be cleaned daily. 5. OP28 The ceiling in the laundry should be repaired. The manager should be mindful that at least 50 of care staff complete the NVQ Level 2 in care as soon as possible. The views collated from residents and other stakeholders about the home should be evaluated so that points of action are highlighted and outcomes for residents considered. Service users should sign the receipt when receiving money from their account. All staff should have at least 6 formal supervision sessions each year. 4. OP26 6. OP33 7. 8. OP35 OP36 The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 23 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 The Hawthornes Care Home DS0000035661.V267174.R01.S.doc Version 5.0 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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