Inspection on 08/08/07 for The Hawthorns

This inspection was carried out on 8th August 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 15 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 10/01/07

The Hawthorns 30/12/05

The Hawthorns 06/09/04

The Hawthorns 21/04/04

Similar services:

Insight - Eastchurch

Southfields

Thorndene

Magenta

Seabourne House

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 Vera Bulbeck Unannounced Inspection 8 August 2007 10:45 th Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 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.V342653.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 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.V342653.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorns (The) Address The Hawthorns Coulsdon Road Caterham Surrey CR3 5YA 01883 383713 01883383714 valerie.martin@subp.nhs.uk 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 and Borders Partnership NHS Trust To Be Confirmed Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th January 2007 Brief Description of the Service: The Hawthorns is on the main site of Surrey and Boarders NHS Trust Headquarters. It is a self-contained building set within a group of homes. All service users have their own single 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 The staff team need to undertake equality and diversity training to ensure the needs of the service users is being met. The fees range from£1,087.55 to £1,455.23 per week. Items that are not covered by the fees include: hairdressing, toiletries, and meals out, nail manicures, some activities and holidays. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced site visit formed part of the key inspection process and took place over eight hours commencing at 10.45 and ending at 19.45pm. Mrs V Bulbeck, Regulation Inspector carried out the visit. A full tour of the premises was undertaken. Two care plans were sampled and the care observed for the two service users. The inspector observed the care provided on the seven service users, the majority of service users have limited communication. Two-service users were able to communicate with the inspector. Four members of staff were spoken to during the visit and a number of records were observed. The home has been operating since July 2006 without a registered manager on site. The current acting manager has been in post a short time. However, she has worked in the home for some time and knows the service users well. The manager informed the inspector that Surrey Borders Partnership NHS Trust was in the process of advertising the manager’s post at the time of the site visit. There were seven service users living in the home on the day of the site visit and there were three vacancies. The inspector would like to thank the service users and staff for their cooperation and hospitality during the inspection. What the service does well: The inspector spoke to a number of service users, and one service users was able to tell the inspector how she feels; all were cheerful and happy they were well dressed and staff stated service users needs are being met. Observation by the inspector was that service users and staff have a good rapport. The inspector spoke with four members of staff on duty on the day of inspection; staff commented they feel supported by the new manager; however, some staff commented morale is low with the state of the premises. The inspector had a discussion with the manager and the manager was able to identify the action and cost of the work that needs to be undertaken to improve the service. The manager also stated she plans to have a number of meetings with staff to ensure all the staff work towards improving the standards in the home. The staff team felt they had to decorate the lounge to improve the living conditions of the home for the benefit of the service users. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The majority of the requirements made at the previous inspection have been actioned except for two. One requirement outstanding is regarding the refurbishment of the home. The management of the home needs to ensure any requirements made as a result of a site visit must be met, if the timescales for any requirements are not suitable these should be discussed with the inspector. The garden needs attention; there was a considerable amount of rubbish in the garden. It was also noted that thistles were at least three foot high and growing around the garden. This could be a health and safety hazard and needs to be cleared immediately. The manager informed the inspector the service users use the garden whenever possible. The garden needs to be attended too and cleared of rubbish to enable the service users to enjoy the garden during the summer months and good weather. The inspector would advise the management of the home to review the laundry facilities, the floor covering outside the laundry is a potential hazard and should be dealt with immediately. The manager informed the inspector the area outside the laundry door has been reported. The inspector would advise the management of the home to keep up to date with the many changes of the Commission for Social Care Inspection and to check on the website on a regular basis. The management of the home also need to ensure a copy of the Care Homes for Younger Adults, National Minimum Standards and the Care Homes Regulations are available in the home to enable staff to use as a working tool. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 7 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 summary of this inspection report can be made available in other formats on request. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 8 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.V342653.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. New admissions to the home are only admitted following a needs assessment to ensure that the home can meet the service users identified needs. The home does not offer intermediate care. EVIDENCE: All service users living in the home have lived in the home for a number of years. Any potentially new service users entering the home would have a pre needs assessment carried out to ensure the home can meet the service users needs. The staff on duty explained that full details of any potentially new service user would be undertaken before the service user enters the home. Also when the service user enters the home the manager explained the admission procedures and criteria to reflect the principles of admission and assessment appropriate to the home. The inspector advised the staff that a copy of the service users guide should be provided to each service user and the document should be in a format to enable the service users to understand. A copy should also be provided to relatives. This document was not checked on this visit, the inspector was informed it is updated on a yearly basis. The home does not offer intermediate care. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users health, personal and social care needs are set out in an individual plan of care, to demonstrate needs are met in accordance with the homes philosophy. Service users confidential information needs to be stored in a locked facility. Systems are in place to enable service users to make decisions and to promote independence. EVIDENCE: Two service users care plans were sampled and there was evidence that service users health, personal and social care needs had been identified and assessed. Care notes were detailed to include service users daily routines. Some service users are able to be involved with their care plan. The care plans hold all the relevant information, however they need to be user friendly to enable staff to use as a working tool. The care plans are kept in the manager’s office, and staff has access to the care plans. Service users care plan should indicate who are unable to hold a key to their bedroom; care plans must be documented to include the reasons Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 11 for not holding a key. Reviews need to be undertaken on all service users, currently there are no care managers involved with any of the service users. One service user informed the inspector she would like to have contact with a care manager this information was passed to the manager to make the necessary arrangements. All service users need to have a review of care with a care manager involved. Staff stated that service users are supported to make decisions affecting their lives in a number of ways. Each person has an allocated key worker, who is trained to offer one to one support and who knows the service user well and understands his or her needs. The majority of service users have limited communication and staff has the experience to enable service users to make some decisions and choices. Holidays, menu planning and outings are mainly with staff support, and generally knowing the service users well. Staff advised that information is provided to service users to assist with decision- making and this is in a format to suit their individual needs. Observation by the inspector, staff are respectful to the service users. It was also noted that service users and staff have a good rapport. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users have opportunities for personal development and to take part in appropriate activities within the home and in the local community. They are supported to maintain and develop appropriate personal and family relationships. EVIDENCE: Service users are supported to make choices in their everyday lives as far as they are able. The inspector would advise the management of the home to involve families of service users to be involved in the decision making process for those service users who are unable to make decisions. The seven service users attend various activities; for example, bowling, shopping, and most service users enjoy pub lunches. Four service users go swimming and two service users like to use the trampoline. Some service users attend the on site day centre. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 13 Three service users are going to Butlin’s for their holidays and another two service users are going to Centre Parc. Another service user is going on holiday with his parents. The home has its own vehicle, which sometimes can be a problem with only four drivers. Only one trip has been undertaken this year and staff took four service users to Bexhill and had a picnic on the beach. This was on route taking a service user to his parent’s house. Staff take service users shopping and for walks around the grounds. On the day of the visit one member of staff went jogging with a service user. Five service users have contact with family members. One service user informed the inspector she goes to church on Sundays and enjoys going to an art class and also likes to play bingo every week. The evening meal was in the process of being cooked and was observed to be nutritional and well balanced. Staff that has undertaken food hygiene training cooks the meals. The inspector was informed service users have a choice of meal; the inspector advised the staff that any changes to the menu must be recorded. A member of staff informed the inspector who was cooking the evening meal, that service users have a good appetite. Staff informed the inspector that service users are involved with the menu planning. The menu is displayed in the kitchen, the inspector stated that service users should be able to see the menu, and suggested that a notice board for the service users be fitted to enable information for example the menu and the complaints procedure could be displayed. Staff supports service users to ensure they eat healthily. Food intake and nutritional content is monitored and all service users are weighed monthly. One service user informed the inspector that she likes to do jobs around the house including her laundry with staff support. Also another two service users undertake jobs and have a routine of jobs to be done. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal care and healthcare support and assistance is planned and was seen in care notes, to be provided, where needed, in a respectful and sensitive manner. EVIDENCE: The inspector was informed by staff that service users are able to choose when to go to bed and when to get up and are supported to choose their own clothes, hairstyles and other aspects of personal grooming. There are regular visits to the local G.P and service users have an annual health check. The medical team as well as other professional health care people, including the dentist and optician when required, constantly observe all service users. A number of risk assessments were seen, risk assessments were in place for each service user, and the manager explained the process is updated on a regular basis. However, the confidential notes currently in the care notes need to be stored appropriately in a locked facility, care plans need to be used as a working tool for all staff. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 15 The system for medication administration was seen and was undertaken by staff that has received medication training. The Medication Administration Record (MAR) sheets were seen for the two service users who were case tracked and it was noted that there were no gaps on the recording records. Staff stated that the member of staff making the entry, signs any additional entries to the MAR sheet that have been handwritten. Two staff signs the MAR sheet for some medication given and for the receipt of medication into the home. Sample signatures of all staff that administer medication were held with the MAR sheets for ease of reference. Consent forms had been signed by the service users. It was noted that PRN medication was not entered on the MAR sheet and some medication needs to be returned to the pharmacist. The inspector would advise the management of the home to review the medication procedures. There are no service users who are able to self medicate. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. All staff have received training in protecting vulnerable people and are aware of the procedures and practices, to ensure that service users are safeguarded, as far as reasonably possible, from harm or abuse. EVIDENCE: There were no recorded complaints. Records seen indicated that complaints would be responded to within the guidelines. The Commission for Social Care Inspection (CSCI) have not received any direct complaints. There was one allegation referred to the Safe Guarding Adult team for investigating and has been completed. The homes complaints procedure for service users is in pictorial form and staff stated that some service users would be able to use it when necessary. The complaints form is written with widget symbols and easy for service users to understand. Some staff spoken to stated they had undertaken training in the protection of vulnerable adults and were aware of the whistle blowing policy. Staff said they would be willing and able to report any concerns and “would go to any level to protect service users”. All service users should be provided with a copy of the service users guide and should include the complaints procedure. Currently these details are in the manager’s office in a glass cabinet behind the desk, and not easily available. A copy displayed in the hallway would be beneficial for all service users, relatives and visitors. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 17 The finances for all service users are maintained by the Trust, it was not clear if service users have their own bank account. Statements are sent to the home with all the service users details and balance on one sheet. This practice is not acceptable under the data protection act. All service users confidential information should be kept separate, and filed appropriately in their personal file. Service users personal allowance is sent weekly from the Trust and is topped up to £20.00. All receipts are sent weekly to the Trust, therefore this standard was not inspected at this site visit. Service users finances should be available in the home for inspection purposes. The home needs to ascertain an up to date copy of Surrey Multi Agency procedures, the copy in the home is dated April 2001. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The premises are in need of attention including the garden, to ensure service users have a safe, comfortable and homely environment to live in. EVIDENCE: The main lounge was found to be clean and well presented, with thanks to the staff team for decorating the area. A number of service users bedrooms were personalised, however some of the bedrooms are in need of decoration. Some of the service users had televisions and music players along with other personal items. It was noted in some of the bedrooms that the carpets are badly stained and a chair in a service users bedroom was also badly stained. A number of bedrooms were without bedside lights. One service user asked the inspector is she could have a carpet in her bedroom, she explained when she gets out of bed the floor is cold. The floor covering was laid for a previous service user and needs to be changed for the present service user. The communal areas in the home are in a poor state of repair, the main corridor and the stairs leading up to bedrooms and lounge had bare wood on Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 19 the stairs and was in need of attention. The stair way needs to be reviewed as service users up and down the stairs are at risk of falling. Handrails need to be fitted in the home, in corridors and the stairway. There were other areas in the home that require attention for example the toilets and bathrooms, one was without a soap dispenser, and all bathrooms and toilets were without hand drying facilities. Each bathroom should have a dispenser for rubber gloves; at the moment the boxes of rubber gloves are left in areas for easy access. There needs to be an indicator on the door of bathrooms and toilets to inform people that the bathroom or toilet is in use. It was also noted that all bathrooms and toilets are in need of up grading. In one toilet the radiator was very rusty and the ceiling was badly stained, there was also a mal odour. In the shower room the ventilation extractor fan was not working, the mirror needs replacing and the light over the mirror was not working. The main light is on all the time, as the switch is not working appropriately. The laundry was in need of attention and the floor covering outside the laundry door is torn and a potential hazard and needs to be attended to without delay. The dining room needs attention the lighting is very low and needs to be changed to more appropriate lighting. The medication cabinet is situated in this room and it is a problem to see even with the lights on. The dining room is in need of decorating. The empty room used, as a staff room/smoking room needs decorating and the carpet is badly stained. The extractor fan is not big enough for the room; therefore the smoke remains in the room causing a potential health hazard. The bin needs replacing and an ashtray that is designed to be more appropriate for a smoking room needs to be installed. The kitchen is in need of being deep cleaned, the work surfaces were badly stained and the lights are in need of cleaning. It was also noted there were several opened packets of cereals; cereals need to be stored in a sealed container once opened. The inspector contacted the Environmental Health Officer (EHO) to ascertain when the last visit was undertaken. The inspector was informed that a visit to the home was due. The visit by the Environmental Health Officer was undertaken and the inspector was informed by the EHO that a number of requirements have been made regarding the kitchen. The garden is in need of attention it was found to have a number of large thistles growing around the garden and the steps leading to the lower level of the garden. It was also noted that rubbish needs to be cleared from the Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 20 garden. The garden needs to be attended to so that service users are able to use the garden during the summer months. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Recruitment and vetting practices need to improve to ensure the safety and welfare of the service users. EVIDENCE: The home has recently appointed a new manager the staff spoken to on the day of the site visit commented that the manager has an open door policy and staff are able to discuss with the manager any issues. The staff confirmed that regular supervision takes place. The present staff team are committed to providing good quality care and informed the inspector they only wish the service users lived in better surroundings. The staff stated they would be happy to paint the living areas of the home. There are four support workers on duty per shift and two waking night members of staff. The staff undertakes the cleaning, laundry and cooking duties. The staffing levels in the home need to be reviewed to ensure service users are able to go out more often. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 22 Staff recruitment files were seen and some were in need of containing a photograph, one record was without a second reference and two files the terms and conditions had not been signed and dated. Relevant documentation as required under Schedule 2 of the Care Homes Regulations 2001, amended version July 2006 must be in place to ensure the service users are protected from harm and abuse. Training is currently being up dated and a number of staff requires updates to their training. All staff needs to attend equality and diversity training, which is not on the current training programme. The inspector would advise the management of the home to ensure all staff attends Infection control training. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The management in the home provides an open, positive and welcoming atmosphere. The home has been operating without a registered manager for some considerable time. The manager should be given more supernumery time to undertake some of the management duties that need to be in place. EVIDENCE: The present acting manager informed the inspector that she has requested to undertake NVQ Level 4 and the Registered Managers Award, and hopes this will commence this year. There are a number of areas that need to be addressed in the home and the manager should be given the time to complete these tasks. The manager is currently working two days a week on management duties and three days a week on shift, and one weekend a month on shift. This practice needs to be reviewed. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 24 Some records were observed and found to be in need of up dating, for example, the fire risk assessment was dated 22/04/04 and an emergency contingency plan needs to be in place for any emergencies. The certificate for the testing of Legionella was dated 10/08/05 this test needs to be undertaken yearly. The testing of the water temperature also needs to be undertaken on a regular basis. All portable appliances need to be checked on a regular basis at least once a year. The recording for the fridge and freezer in the kitchen and the storeroom needs to be undertaken daily and the testing of the temperature of cooked meat needs to be undertaken when necessary. The cleaning schedule for the kitchen does not correspond with the records kept in the handover book. The upright freezer in the empty bedroom used as a storeroom needs cleaning and defrosting. The kitchen needs to be deep cleaned and work surfaces are badly stained. The lights in the kitchen need to be cleaned of dead flies. The kitchen is in a poor state and needs redecorating. All dried foods including cereals need to be stored in a sealed container. All bathrooms and toilets need appropriate hand washing facilities. One of the toilets had a mal odour. All staff needs to attend Infection control training. The management of the home to ensure a copy of the Care Homes for Younger Adults National Minimum Standards are available in the home and a copy of The Care Homes Regulations 2001 and the updated amended version should be available for the staff to use as a working tool. Regular monitoring Regulation 26 visits take place and the reports seen were informative and the person undertaking the visit is clear regarding the content of the report. The manager stated that she intends to undertake an annual survey this has already commenced with sending the surveys to G.P.’s. Service users, relatives, and other professionals need to be included in the survey. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 25 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 1 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X X X 3 X X 2 X Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 26 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 YA24 Regulation 23(2) Requirement It is required that an immediate programme of refurbishment of communal areas is undertaken. (Timescales not met 31/03/06, 10/03/07). The RI must ensure that a manager make an application to be registered by the CSCI. (Timescale 10/03/07). Medication procedures need to be reviewed. The floor covering outside the laundry must be replaced. This is a potential health and safety hazard. The environment in the home must be completely redecorated and bathrooms and toilets must be upgraded. The garden must be cleared of rubbish and cleared of weeds/thistles. The kitchen must be deep cleaned and must be decorated. The lights must be cleaned. Recruitment procedures must be followed as detailed in Schedule 2. DS0000013667.V342653.R01.S.doc Timescale for action 21/09/07 2. YA37 9(2) 21/09/07 3 4 YA20 YA24 13 12 09/08/07 31/08/07 5 YA24 23 09/11/07 6 7 YA24 YA24 23 23 31/08/07 24/08/07 8 YA34 19 31/08/07 Hawthorns (The) Version 5.2 Page 27 9 10 YA35 YA42 18 13 11 YA42 13 12 YA42 13 13 14 15 YA42 YA42 YA42 13 13 13 All staff requires training regarding equality and diversity and infection control. Records need to be kept up to date regarding water temperatures, testing of cooked meat and fridge and freezer temperatures. To ensure a fire risk assessment is up to date and to have in place an emergency contingency plan. The water needs to be appropriately tested for Legionella and a certificate available. All portable appliances need to be checked and a record available. All dried foods once opened including cereals must be stored in a sealed container. Handrails need to be fitted in corridors and on either side of the stairs. 21/09/07 09/08/07 21/09/07 21/09/07 21/09/07 09/08/07 21/09/07 Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 28 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 7 8 9 10 Refer to Standard YA9 YA2 YA7 YA23 YA23 YA39 YA39 YA42 YA42 YA42 Good Practice Recommendations All service users to be provided with a service users guide including a complaints procedure in a format suitable for service users. Care plans need to be separated and confidential information stored appropriately. To record service users choice of meal. An up to date copy of Surrey Multi Agency Procedures to be available. Service users finances must be available for inspection purposes. To ensure the home has a copy of the National Minimum Standards for Younger Adults and The Care Homes Regulations 2001 amended version. Management need to undertake a Quality Audit in the home for service users, relatives, and professional people involved in the care of the service users. The doors around the home, which are currently locked, need to be reviewed. The cleaning schedule needs updating. Fire records to be contained in one folder. Hawthorns (The) DS0000013667.V342653.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Oxford Area Office Burgner House 4630 Kingsgate, Cascade Way Oxford Business Park South Cowley Oxford OX4 2SU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. 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