Inspection on 27/06/05 for The Hawthornes Care Home

This inspection was carried out on 27th June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Poor. 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 24/11/05

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 Jim Leyland Unannounced 27 June 2005 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 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 J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service The Hawthornes Care Home Address Bradford Road Birkenshaw West Yorkshire BD11 2AN 01924 284200 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Tri-Care Limited Care home 40 Category(ies) of 40 x Old age (over 65 years) registration, with number of places The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 26 January 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 J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced inspection to The Hawthornes. This commenced at 10am and concluded at 4.30pm. Ten residents, five members of staff, the manager and area manager spoke with the inspector. A tour of the building took place and staff records, care plans and other documentation were examined. Thank you residents, staff and managers for your welcome, assistance and hospitality during the inspection visit. What the service does well: What has improved since the last inspection? What they could do better: There are several areas where improvements are required in the home. Some concerns must be followed up at the earliest opportunity. These relate to the recording and storage of medication, ensuring plans setting out the care needs of residents are detailed and have goals and undertaking fire tests and drills on a regular basis. More domestic staff would improve hygiene standards. Residents need to be protected by thorough checks taking place on new staff coming to work at the home. The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 6 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 J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 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 standard(s) 2 and 3 Residents have a contract when they move into the home, although, not all of these have been signed. Residents’ needs are assessed prior to admission to determine whether or not the home can meet these needs. EVIDENCE: Each resident is provided with a statement of terms and conditions with the home. The document includes the relevant information set out in the standard, including fees payable and the rights and obligations of the provider and the resident. Two contracts were examined and neither had been signed or dated to make them legal and binding. Three residents’ files were checked and all three had a pre-admission assessment, two who were self-funding, that had been carried out by the home and one community care assessment carried out by a social worker. The private admissions are assessed using a Tri-Care pro forma covering the elements set out in the standard. The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 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 standard(s) 7, 8 and 9 Care plans lack sufficient detail about how the needs of residents are to be addressed and records lack evidence of how these needs are being met. The health needs of residents are met, however some information was not available to fully evidence this. The standard of the storage and recording of medication in the home was poor and must be addressed. EVIDENCE: Three care plans were examined. Two of these contained a personal support plan setting out the basic needs and preferences of residents. One person, who required minimal care, said that they had not been supported to complete a personal support plan. Where residents have complex needs, care plans must be more detailed, setting out goals and outcomes for residents and detailing actions on how these will be met. Daily records do not reflect the input that staff have in supporting residents. Risk assessments and moving handling plans are completed for residents, however some of these were overdue for review. There is evidence that the staff and managers at The Hawthornes refer to and liaise with health care professionals to ensure that the health needs of residents are met. Examples include a referral to psychiatric services due to a The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 10 person becoming more confused and disorientated. Also residents are supported to access a GP and receive regular dentist and chiropody appointments. Appropriate assessments pertaining to tissue viability, nutrition and continence are completed. However one recently admitted resident, with minimal needs has not been assessed. These should be completed to provide a baseline assessment. Secondly the weight of one resident was recorded, highlighting a significant loss, but has not bee monitored for four months, to gauge any concerns. A requirement is made as staff have not communicated the special dietary requirements of a resident to the cook, compromising the health and safety of the individual. There are medication rooms on both floors. The manager has obtained two controlled drugs books, following a recommendation at the last inspection. The storage of medication gave some cause for concern. Medication was placed in dispensing pots without labels; paracetamol was placed in one of the trolleys and had not been prescribed. All medication must be accounted for to protect residents. It is also recommended that a list of authorised signatures is included in the medication records. A recommendation is made that when medication is discontinued that a line is drawn on the MAR sheet to avoid confusion. In terms of controlled medication, all controlled drugs must be recorded in the controlled drugs book when a person is admitted to the home, even if they are admitted for a period of respite. Some staff have completed medication training, however all staff who administer medication must receive appropriate training. The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 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 standard(s) 12, 13 and 14 Various activities are offered in the home, however more emphasis is needed on considering individual preferences. Residents are able to receive visitors at any reasonable time. There is clear evidence that residents receive choice about living in the home and that their rights are protected. EVIDENCE: Some residents enjoy going out themselves, for example one resident said that they had been out for a bus ride and lunch on the day of the inspection. A second resident was choosing a book to read from the small library in the home. Residents said that they enjoyed visiting singers and entertainers coming to the home. There are some structured activities in the home, for example quizzes, bingo and dominoes. However, some said that there were some days that few, if any activities took place. It is recommended that the social needs of residents are assessed and that daily records provide evidence that these activities are taking place. Daily records show that residents receive visits from their families and are able to choose whom they do and do not see. Minutes from residents’ meetings were seen showing that the home aim to involve residents and relatives in issues about the home. The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 12 Residents receive choice about all aspects of their care, the food, lifestyle and are able to manage their finances for as long as they are able to do so. Details about how to contact advocacy services are advertised on the notice board. Care plans provide details about whether or not residents have a power of attorney or representative to act in their interests. The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 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 standard(s) 16 and 18 Residents and their relatives feel comfortable to raise any concerns and know that these will be listened to and acted upon. Residents are protected by trained staff, who are aware of adult protection procedures. EVIDENCE: The home has a satisfactory and accessible complaints procedure. A recently admitted resident was aware of how to pursue a complaint and said that they felt the staff were approachable to raise any concerns. There is a detailed complaint’s pro forma, setting out the nature of the complaint, any actions taken and the outcome for the complainant. Minutes from a residents’ meeting confirmed that various issues have been brought up by residents and that staff have responded to these concerns. Virtually all of the staff have completed or are in the process of undertaking Adult Abuse training. Staff are aware of how to report poor practice through the whistle blowing policy. Policies are also in place for managing aggression, around staff not benefiting from residents’ wills and in relation to gifts, gratuities and bequests to staff. A requirement is made as the balance of one resident’s money did not balance and several pounds could not be accounted for. Closer auditing of residents’ monies is needed. The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 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 standard(s) 26 The home is clean and hygienic, Some improvements in the laundry would promote more rigorous infection control. EVIDENCE: There is a well equipped laundry in the home. There is no dedicated laundry person, these tasks are carried out by care staff. There are some issues relating to laundry going missing, which need to be addressed. Paper towels in the laundry should be made available in the laundry to promote infection control. The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27, 28, 29 and 30 More staff are needed in order that the needs of residents are fully met, in particular domestic and kitchen duties. Progress is being made on the numbers of staff who have completed their NVQ Level 2 in care. All relevant checks for staff must be completed before a person commences work in the home. Staff receive a comprehensive induction in order that they are trained and competent to do their jobs. EVIDENCE: Residents’ care needs are met by sufficient numbers of staff, however some tasks, notably domestic duties are being compromised. At present the home has only one dedicated cook and senior staff are working extra hours to cover this. The home currently has no dedicated domestic staff available and basic cleaning is being undertaken by care staff. Whilst the rotas show that there are sufficient numbers of care staff; the addition of laundry and cleaning duties to their tasks could compromise the needs of residents. Some residents commented that their rooms were not as clean as they would like. Seven staff have completed their NVQ Level 2 in care and the manager pointed out that a further five have commenced the qualification. The manager should be mindful that these people complete the course to ensure that at least 50 of staff have NVQ Level 2 or above. The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 16 Three staff files were checked. Most of the required information was available for inspection, including two written references and identification. All three Members of staff had an enhanced Criminal Records Bureau check in place, however one of them was from a previous employer. Therefore the appropriate CRB and Protection of Vulnerable Adults checks have not been undertaken. Residents must be safeguarded by rigorous recruitment practices. The area manager explained that each home would be given more autonomy to collate the recruitment information to overcome such issues. New staff complete training to equip them to do their job, including mandatory health and safety training, induction to the home, care planning and adult abuse training. The induction provides training on the principles of care, safe working practices and the particular needs of the people living in the home. The manager said that there are plans for staff to do experiential training to help them carry out their role effectively. The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36 and 38 A new registered manager has now been appointed in the home, who is sufficiently experienced to carry out this role, but needs to complete the appropriate qualification. The residents and their relatives are consulted about the home, however a more effective quality assurance procedure is recommended. Staff receive supervision, however some staff have not had supervision for many months. The system for recording fire tests, drills and training must be dealt with in order to safeguard residents and staff in the home. EVIDENCE: The manager appointed earlier in 2005 has now been registered with the CSCI. She has completed the NVQ Level 3 in care. It is recommended that the manager complete the NVQ Level 4 in management and care, which she has commenced. The manager is supported by two deputy managers and there The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 18 clear lines of accountability and support from the recently appointed area manager. Relatives and their families receive questionnaires to seek their views about The Hawthornes. There is also a comments book to log the views of visiting professionals and other stakeholders. These views need to be evaluated so that points of action are highlighted and outcomes for residents considered. Staff receive supervision, which covers issues about care practice, training and career development. Supervision records show that some staff have had regular supervision, however others have not. All staff in the home should receive formal supervision at least six times per year. The home has a fire risk assessment place, completed last year. Weekly fire tests take place, however there are several missed weeks when the person responsible for them has been away from the home. Provision must be made to ensure that the tests are carried out weekly. Secondly no fire drills have taken place in recent months. All staff must participate in at least two drills per year, so that they are aware of the procedure to follow. The manager provided evidence that staff are due to attend a fire safety course in the near future. The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x 2 3 x x x HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 1 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 x COMPLAINTS AND PROTECTION x x x x x x x 2 STAFFING Standard No Score 27 1 28 2 29 1 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x 1 2 x 2 x x 2 x 1 The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 20 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. Standard 7 Regulation 15(1) Requirement 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. The registered person must promote and make proper provision for the health and welfare of service users: The cook must be aware of any special dietary requirements of service users. The registered person shall make 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. The registered person must make arrangement for the safekeeping of medicines and account for medication held in the home. Financial rcords for service users must be kept up to date and monitored,as some records are inaccurate and there are some Timescale for action 31st July 2005 2. 8 12(1) 31st July 2005 3. 9 13(2) 31st July 2005 4. 9 13(2) 31st July 2005 5. 18 17 Schedule 4 31st July 2005 The Hawthornes Care Home J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 21 discepancies. 6. 27 18(1)(a) The service provider must, 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, especially domestic staff, to promote the health andwelfare of service users. This is an outstanding requirement from 26/01/05. The registered person must ensure that staff working at the home have upto date Criminal Records Bureau checks and Protection of Vulnerable Adults checks. The registered person must ensure that staff take part in fire drills minimum of twice a year and weekly checks of the fire alarm system are undertaken and recorded. 31st July 2005 7. 29 19 Schedule 2 31st July 2005 8. 38 23(4) 31st July 2005 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. 5. 6. Refer to Standard 2 7 8 9 9 12 Good Practice Recommendations Both parties, i.e. service user and provider need to sign the contract of terms and conditions when the service user moves into the home. Risk assesments 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 a list of authorised signatures is included in the medication records. A recommendation is made that when medication is discontinued that a line is drawn on the MAR sheet to avoid confusion. It is recommended that each service user has an individual assessment to ensure that they are offered the opportunity J51J01_s35661_The Hawthornes_v220865_270605.doc Version 1.40 Page 22 The Hawthornes Care Home 7. 8. 9. 10. 26 28 31 33 11. 36 to participate in fulfilling activities. Paper towels should be providedin the laundry to promote infection control. The manager should be mindful that at least 50 of care staff complete the NVQ Level 2 in care as soon as possible. The manager shoild complete the NVQ Level 4 in manaagement and care by the end of 2006. The views collated from residentsand other stakeholders about the home should be evaluated so that points of action are highlighted and outcomes for residents considered. All staff should at least 6 formal supervision sessions each year. 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