Inspection on 19/09/06 for The Hawthorns

This inspection was carried out on 19th September 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

The Hawthorns 12/09/05

The Hawthorns 11/04/05

The Hawthorns 13/09/04

The Hawthorns 07/04/04

The Hawthorns 26/01/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE The Hawthorns Hawthorn Street Wilmslow Cheshire SK9 5EJ Lead Inspector Jayne Telfer Key Unannounced Inspection 19th September 2006 09:00 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 Hawthorns DS0000006541.V309467.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. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hawthorns Address Hawthorn Street Wilmslow Cheshire SK9 5EJ 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) 01625 527617 01625 539398 www.clsgroup.org.uk CLS Care Services Limited Kenneth Kingsmill Care Home 39 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (38) of places The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home is registered for a maximum of 39 service users to include: * up to 38 service users in the category of OP (old age not falling within any other category) * one named service user in the category of DE(E) (dementia over the age of 65 years) who may be accommodated within the total of 39 beds Date of last inspection 12th September 2005 Brief Description of the Service: The Hawthorns is a purpose built care home for older people requiring personal care run by the CLS Group, a non-profit making organisation based in Cheshire and Wigan. The care home is in a residential area about ten minutes walk from the centre of Wilmslow. It is on 2 floors and there is a passenger lift to both levels. Five of the 39 single rooms have an en suite toilet and washbasin; the rest of the rooms have washbasins in them and toilets nearby. There are four lounges, two dining rooms, a small sitting area in the entrance hallway, and a fully equipped hairdressing room. There are a variety of aids and adaptations around the building to allow people who live there to move about more independently. There is a garden with benches in an enclosed patio. Current Fees for this Service: £343 - £450 per week. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This Key inspection was unannounced and started at 9.00am and took place over six hours. The Registered Manager was also invited to provide evidence as part of this process. The Inspector spoke to the Registered Manager, two staff members, and seven residents and their views were taken into account. Four residents’ records were examined as part of the inspection process, in respect of the care they receive. Records of medication, care plans staffing rotas and training were also examined. A tour of the premises was undertaken. Examination of the home’s documentation, policies and procedures formed the basis of the visit. What the service does well: What has improved since the last inspection? The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 6 All requirements and recommendations addressed appropriately. from the last inspection were 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 Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 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 Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 Quality in this area was judged to be good. This judgement has been made using available evidence including a visit to the service. Prospective residents and their representatives have the information needed to choose a home which will meet their needs. They have their needs assessed and a contract which clearly tells them about the service they will receive. Standard 6 does not apply. EVIDENCE: The Service User Guide is clear and detailed. It contains a range of information regarding the service and is available in each resident’s room. Although it is printed in large print, it is not available in other formats, such as pictorial, auditory or differing languages. The Registered Manager stated that the use of other formats was being planned. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 9 All residents who were case tracked had had detailed pre-admission assessments completed by both The Hawthorns and an appropriate professional (for example a social worker). Copies of the statement of terms and conditions available in the Service User Guide. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 and 10 The quality in this area is good. This judgement has been made using available evidence including a visit to the service. The health and personal care, which a resident receives, is based on their individual needs. The principles of respect, dignity and privacy are put into practice. EVIDENCE: Care plans were noted to be appropriately detailed and individual. Health needs were well documented and monitored, for example records and reviews of Waterlow scores (monitoring pressure areas), falls risk assessments and nutritional assessments were seen. Individual files also contained details of contacts with health professionals. During the site visit, the District nurse was observed to discuss appropriate treatment plans with a staff member, showing that there is good communication between staff and health professionals at The Hawthorns. This means that residents are likely to receive appropriate care. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 11 Care plans were regularly reviewed. Residents could be more involved in the drawing up of their own care plans, although it was evident that residents took part in the care plan reviews. During the last resident survey a couple of residents indicated that their dignity was not upheld. The Hawthorns investigated this and provided additional staff training around the issue. None of the residents spoken with during the site visit raised the issue, in fact they all said that staff were very good. Comments such as ‘they are very kind’ and ‘they’ll do anything for you’ were heard. There was a good, clear medication system in place. Stocks were appropriate for the size of the home. Medication was stored appropriately and securely. Records were up to date and in good order. At the time of the site visit, three residents were self-administering their medication. This is good practice by the Home. Appropriate risk assessments and systems were in place for these residents, for example, staff did weekly stock checks. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this area is good. This judgement has been made using all available evidence including a visit to the service. Residents are able to choose their life style, social activity and keep in contact with family and friends. Social, cultural and recreational activities meet resident’s expectations. Residents receive a healthy, varied diet according to their assessed requirement and choice. EVIDENCE: A new activities coordinator had been employed at The Hawthorns and was being inducted during the site visit. Activities available to residents were displayed on a white board in lounge. There were no notices regarding available activities upstairs in the Home, so residents had to go downstairs to see what was going on. Activities such as music, bingo, gentle exercises are offered regularly. Representatives of local faiths attend the Home regularly, for example there is a weekly catholic mass, and the Christian Fellowship visit The Hawthorns and conduct prayers and hymns. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 13 The Hawthorns has an open visiting policy. Residents are able to receive visitors in the lounges, or their own bedrooms. Visitors were observed to be made welcome at The Hawthorns. Residents meetings are held regularly, these are minuted and the minutes distributed. The Hawthorns also has it’s own newsletter which informs residents about events and changes at the Home. Residents were complimentary about the food at The Hawthorns. One commented ‘it’s just like I would make myself at home’ and another said ‘it is superb!’ Menus are varied and choices are offered. The cook said he enjoyed ‘treating’ the residents with home baked cakes as often as he could. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Quality in this area is good. The judgement has been made using all available evidence including a visit to the service. Residents have access to a robust, effective complaints procedure, are protected from abuse and have their legal rights protected. EVIDENCE: One complaint was received since the last inspection and this was regarding staffing levels. The complaint was responded to appropriately by the Home and actions put in place to ensure the situation does not arise again. The Hawthorn’s Complaint policy was appropriate and was displayed in the home. Other methods of raising concerns are through a ‘suggestion book’ and via the resident meetings. Adult protection policies and procedures were appropriate. There had been no incidents arising since the last inspection. Staff receive appropriate training regarding Adult Protection. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 24 and 26 Quality in this area is good. The judgement has been made using all available evidence including a visit to the service. The physical design and layout of the home enables residents to live in a safe, well-maintained and comfortable environment, which encourages independence. EVIDENCE: The Hawthorns is currently undergoing a redecoration programme, which includes the changing of the bathroom floors. The building was seen to be clean, hygienic and well-maintained. The décor is pleasant and homely, and the Home has good lighting and appropriate ventilation. The Hawthorns offers various communal spaces for residents: downstairs has a main and a smoking lounge. There is also an activities room and a small kitchen in which relatives can make a drink. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 16 Upstairs, at The Hawthorns there is a small library, a lounge and a dining/kitchen area. Bedrooms are individually decorated and five rooms have en-suite facilities. Residents are encouraged to bring in personal belongings in order to individualise their rooms. Laundry facilities are appropriate, and the Registered Manager and the staff team are discussing changing the current system to a different procedure involving coloured bags, this will improve infection control systems. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Quality in this area is good. The judgement has been made using all available evidence, including a visit to the service. Staff in the home are trained, skilled and in sufficient numbers to fill the aims of the home and meet the changing needs of residents. EVIDENCE: One complaint regarding staffing levels had been received at The Hawthorns, and as a result the Home is closely monitoring staffing. The rotas show appropriate staffing levels for the dependency of the residents, and residents said they believed there were enough staff on duty. One resident commented, ‘they are always there when you need them’. The Hawthorns does use some Agency staff, the use is below 2 , and covers for sickness and absence. The Registered Manager stated that generally the staff team were willing to cover shifts for each other when necessary. Seven staff members are qualified to NVQ level 2 or above, and more have almost completed the qualification, which will mean that 50 of the staff team will have the appropriate qualification. Recruitment procedures are good. The procedures are followed and correct documentation obtained, ensuring that residents are protected and supported by appropriate care staff. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 18 Staff have access to a variety of basic training, this includes medication, moving and handling, fire and first aid. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 19 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38 Quality in this area is good. The judgement has been made using all available evidence including a visit to the service. The management and administration of the home is based on openness and respect, has effective quality assurance systems developed by a qualified, competent manager. EVIDENCE: The Registered Manager is a registered nurse and also holds his Registered Manager Award. He is an experienced manager and staff commented that he was approachable and communicated well. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 20 The Quality Assurance system included resident surveys, which were audited appropriately. Information gathered from the surveys is published in the Service User Guide. The Registered Manager also gathers information through staff and resident meetings, regulation 26 reports, audits of medication, care plans, falls and sickness. The Quality Assurance procedure contributes to the annual training plan and the Business Plan. CLS achieved Investors in People status and the award in December 2005. Resident finances are appropriate procedures. secured through appropriate documentation and Health and safety policies, procedures and assessments are appropriate. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 X X 3 The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? no 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. Standard Regulation Requirement Timescale for action 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 OP1 OP7 OP12 Good Practice Recommendations It is recommended that the Service User Guide is made available in different formats. It is recommended that residents are more involved in the drawing up of their care plans. It is recommended that the activities and events at The Hawthorns are displayed upstairs as well as downstairs. The Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Northwich Local Office Unit D Off Rudheath Way Gadbrook Park Northwich CW9 7LT 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 Hawthorns DS0000006541.V309467.R01.S.doc Version 5.2 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. 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!