Inspection on 30/12/05 for The Hawthorns

This inspection was carried out on 30th December 2005.

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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

The Hawthorns 21/07/08

The Hawthorns 08/08/07

The Hawthorns 10/01/07

The Hawthorns 06/09/04

The Hawthorns 21/04/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

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33 St John`s Church Road

Dovedale Court

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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 Hawthorns (The) The Hawthorns Coulsdon Road Caterham Surrey CR3 5YA Lead Inspector Peter Benthom Unannounced Inspection 30th December 2005 10:00 Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 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 Hawthorns (The) DS0000013667.V252658.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 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. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hawthorns (The) Address The Hawthorns Coulsdon Road Caterham Surrey CR3 5YA 01883 383713 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) Surrey Oaklands NHS Trust Mrs Simla Panchoo Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The age/age range of the persons to be accommodated will be:21-64 YEARS 1st June 2005 Date of last inspection Brief Description of the Service: The Hawthorns is on the main site of Surrey Oaklands NHS Trust Headquarters. It is a self-contained building set within a group of homes. Each service user has their own bedroom. There is ample garden space to the rear of the property, which has a patio area; the rest of the garden is laid to lawn. The building is a modern bungalow style property providing accommodation for service users on the ground floor only, however there are some steps within the building. There are local shops and pubs within walking distance of the home, other community facilities, such as the library and swimming pool are reached by using the home’s own transport or local bus services. Many day care facilities are provided for service users on the Trust’s Headquarters’ site. A few service users attend activities within community facilities, such as local education services. The service users have a complex range of needs; including challenging behaviour Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was second of the year 2005/6 and was conducted by an inspector from CSCI. The manager is has been registered for some considerable time and was present for the inspection. Five members of staff were on duty all the Service Users in the home were spoken with. A tour of the premises took place and care, personnel; staff meeting and medication records were inspected. What the service does well: What has improved since the last inspection? What they could do better: It was observed that the home is operating well and that all policies, procedures and practice issues are of a good standard. However the communal areas of the home are in urgent need of refurbishment as they look shabby and institutional. The floor covering in the corridors is worn and hazardous in places and the walls and paintwork are damaged and dirty. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 6 In addition, the manager must commence must recommence her NVQ Level 4 and Registered Manager’s Award training as soon as is practicable in order to meet the National Minimum Standards for Adults. Please see requirements on page 21 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. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 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 Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 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): 1, 2, 3, 4 and5 Service users are admitted only following a full assessment undertaken by the manager who was able to demonstrate the homes capacity to meet the assessed needs. EVIDENCE: The home had a comprehensive statement of purpose, which accurately depicted the services provided by the home. All potential service users are assessed prior to admission. It was reported that the service only admits new service users based on an assessment of needs, and appropriateness of placement The initial assessment was used to form the basis of the care plan and the support plan, which identified the actions that carers should follow to assist an individual living at the home. The home manager carries out assessments of prospective service users. Overall care plans were very well documented The organisation’s policy on transitional arrangements and admission process is detailed in the Statement of Purpose and Service Users Guide. The home provided a high level of individualised support to service users. This was a commendable part of the home’s operation. The home provides a good quality of care for its Service Users. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 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, 7, 8, 9 and 10 The systems for Service User consultation that are in place provide evidence of Service Users views being accurately reflected. EVIDENCE: Each Service User had been involved in the development, of their care plans. These care plans clearly identified the Service Users wishes and expectations and full information about Service Users likes and dislikes. Evidence was found that Service Users are involved in day-to-day participation in the running of the home and are given the opportunity to be involved in activities. During the inspection it was evident that staff respect the Service Users’ right to make decisions. Staff enabled Service Users to take responsible risks - wherever possible – and this was clearly documented in each individual care plan. Risk assessments were being carried out as/when necessary and existing ones regularly updated. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 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): 11, 12, 13, 14, 15, 16 and 17 Links with relatives, friends and the local community are good. These links support and enrich Service Users social and educational opportunities EVIDENCE: Examination of the home’s records confirmed a high degree of personal empowerment and choices in services users daily lives. They were encouraged and supported in the use of community amenities and in maintaining relationships with friends and families. The activities programme was individualised in accordance with Service Users wishes and made appropriate use of college courses, community amenities and facilities. All Service Users go out into the local community on a regular basis supported by members of care staff. Service Users are offered a healthy diet with multiple choices and participate as much as possible in the planning of menus and shopping lists. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 11 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 and 21 The personal and healthcare needs of Service Users are well met with evidence of good consultation with other professionals taking place on a regular basis. Medication arrangements were satisfactory. EVIDENCE: There were appropriate links with other health professionals on the day of inspection. The home’s GP has a good knowledge and understanding of the needs of the Service Users and provides good support to the home. All Service Users attend the optician, chiropodist, dentist and physiotherapist as needed. Adequate arrangements were in place to meet the health care needs of Service Users. The home has a key work system in place. Key workers are responsible for ensuring that Service Users receive personal support in a way they prefer and/or require and this is documented in the care plans. Bathrooms and toilets were fitted with locks for privacy. Staff were observed to respect the privacy of Service Users’ bedrooms within appropriate guidelines and procedures. All Service Users are registered with the local GP and have access to all NHS healthcare facilities as required. Service Users will receive support from members of staff e.g. offering support to and from appointments. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 12 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 and 23 The home has a satisfactory complaints system that is made available to all Service Users and staff. EVIDENCE: The Trust had formal complaint procedures and service users were provided with a visual complaint procedure in the service user’s handbook. This had been issued to each person. The Trust had internal adult protection procedures and a copy of Surrey County Council’s Adult Protection Procedures. The Trust has taken steps to ensure that all staff are re-trained in aspects of adult protection and ensured that senior staff also received training concerning dealing with poor staff practice that they may encounter when in charge of the home. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 13 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, 25, 26, 27, 28, 29 and 30 The condition of essential décor in some parts of this home is of a very poor standard with no satisfactory evidence of improvement through maintenance and refurbishment. EVIDENCE: The premises were seen to be appropriate for service users’ lifestyles and needs and accessible to relevant community facilities and services. Space standards in all bedrooms were in compliance with the National Minimum Standards for Adults (18 – 65). All of the Service Users bedrooms were furnished and decorated to a reasonable standard and they contained numerous personal effects that recognised the personal needs and lifestyles of the occupant. This service has two large lounges and a dining room that is appropriately furnished. On the day of the inspection the Service User were observed using all of these areas and the member of staff present was seen to be interacting appropriately with the Service User in all areas of the home. However the communal areas of the home were found to be shabby and institutional with no evidence of refurbishment or proper maintenance. The floor covering is worn and hazardous in places and the condition of the paintwork of the walls and doors is worn and damaged. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 14 Please see requirements on Page 21 Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 15 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): 31, 32, 33, 34, 35, and 36 The manager is supported well by the senior staff in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: Staff spoken to at the day of the inspection had a good understanding of their job descriptions and their responsibilities and they were able to identify the roles of other members of staff in the hierarchy. Communication between staff was good. Training and development of staff has been given a high priority with staff doing the NVQ and a range of other training to help them care for and support the service users. There are currently 6.5 full time posts vacant tin the home and these gaps in the rota are being covered by bank and agency staff. There are arrangements in place for all staff to have regular access to training and a commitment from the organisation to provide staff with NVQ training. The Home is committed to a rolling programme of NVQ training for all staff. Staffing levels comply with National Minimum Standards. The manager is involved in all aspects of staff recruitment and policies and procedures were in place for recruitment and employment. Records of good practice were seen in the Home. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 16 There are arrangements to carry out CRB checks and two written references are required for all staff. However it was noted that some personnel information is still being kept at the Trust’s headquarters which are adjacent to the service. All information relating to staff recruitment and training must be kept in the home. Please see requirements on Page 21 Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 17 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, 38, 39, 40, 41, 42 and 43 The manager is well supported by the senior staff team and by the organisation in providing clear leadership throughout the home with all staff demonstrating an awareness of their roles and responsibilities. EVIDENCE: The manager has had extensive relevant experience in the management of a care home, but has yet to achieve her NVQ Level 4 in management and the Registered Managers Award. It is essential that she recommence this training at the earliest opportunity. Please see requirements on Page 21 Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 18 Records examined included; care plans, medication procedures, staff meeting minutes, risk assessment policies and service user activity programmes. Detailed policies and procedures were in place in relation to safe working practices. Staff were trained in First Aid, Food Hygiene and other aspects of Health and Safety. Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hawthorns (The) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000013667.V252658.R01.S.doc Version 5.0 Page 20 No 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 YA37.2 Regulation 9(2)(b)(i) Requirement It is required that the manager re-commences NVQ Level 4 and the Registered Manager’s Award at the earliest opportunity. It is required that all personnel information is kept within the home. It is required that an immediate programme of refurbishment of communal areas is undertaken. Timescale for action 28/02/06 2 3 YA41 YA24.12 19(1)(c) Schedule 2 23(2)(b) 31/01/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. N/a Refer to Standard N/a Good Practice Recommendations N/a Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Surrey Area Office The Wharf Abbey Mill Business Park Eashing Surrey GU7 2QN 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 Hawthorns (The) DS0000013667.V252658.R01.S.doc Version 5.0 Page 22 - 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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