Inspection on 26/09/05 for The Hawthorns Care Home

This inspection was carried out on 26th September 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

The Hawthorns Care Home 10/03/09

The Hawthorns Care Home 16/01/07

The Hawthorns Care Home 06/09/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

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

CARE HOMES FOR OLDER PEOPLE Hawthorns (The) 5 Burlington Road Buxton Derbyshire SK17 9AR Lead Inspector Stuart Hannay Unannounced Inspection 12:30 26 September 2005 th 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 Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hawthorns (The) Address 5 Burlington Road Buxton Derbyshire SK17 9AR 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) (01298) 23700 Salvation Army Capt. Fiona Joyce Mugford Care Home 34 Category(ies) of Old age, not falling within any other category registration, with number (34) of places Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th January 2005 Brief Description of the Service: The Hawthorns is a care home registered to provide personal care and accommodation for up to 34 older people. It is situated in the town of Buxton in the Peak District. It is close to a park and formal gardens and there is access to local amenities such as the theatre and shopping centre. The home is on three floors and has a passenger lift, 32 single bedrooms, 22 of which are en suite. There are 3 lounges, 2 of which are on the ground floor and 1 on the second floor. Gardens are provided including a sensory garden. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Seven service users and one relative were interviewed on the day of the inspection. A check was made of the fire testing and training records and four care plans were checked. An inspection was made of the bedrooms, corridors, bathrooms and lounge areas and the previous requirements were checked with the manager. The staffing rotas were seen to check staffing levels. What the service does well: What has improved since the last inspection? A programme of redecoration had commenced at the home as required in previous inspections. Measures had been taken to improve service users’ privacy in the bathrooms and handwashing facilities had been provided in the laundry. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Assessments are made of the service users prior to admission to the home to ensure their needs can be met. EVIDENCE: Of the four care plans checked, one person had been admitted in the previous 12 months and a full assessment had been made of her needs prior to her entering the home. Other care plans contained assessments made by professionals, such as nurses or social workers. It had been noted in previous inspections that pre admission information was not available and the home need to ensure that this is consistently obtained in line with current practice. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 10 Information is available in the care plans to ensure that health, personal and social care needs are met. However, inconsistencies in the way the plans are completed and reviewed could potentially mean information is missed. EVIDENCE: Four care plans were checked in detail. They contained a range of health assessments, including weight charts and risk assessments and leisure and social interests had been included. The ‘Personal Care Plan’ described what action staff needed to take to meet the needs of service users. Three of the service users interviewed described their care needs and the care plans examined matched these descriptions. Service users said that they had been able to discuss their care with staff. The plans contained records of contact with GPs, hospitals, district nurses and chiropodists. Although the care plans had been reviewed on a regular basis, the reviews did not appear to have taken account of significant changes identified in the daily information notes – these included continence patterns or serious illness. The daily notes indicated that the care provided to the service users had changed, however this information had not been changed in the ‘Personal Care Plan’, which highlights what staff intervention is needed to meet peoples’ needs. The care plans Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 10 contained dietary preferences but did not all contain nutritional assessments. The quality of the daily recordings was variable, many did not relate consistently to the issues identified in the ‘Personal Care Plan’ and the language used in some of the entries could be considered as pejorative or judgemental. The newly appointed manager showed the inspector a new care planning format, which should address some of the identified problems when it is fully implemented. All the service users interviewed felt that staff treat them with respect, dignity and kindness. Some service users were not able to clearly describe their needs due to apparent communication problems linked to dementia – they looked well- cared for and clean. Service users glasses, hearing aids and dentures appeared to be well looked after. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 13 14 15 Service users have choices about how they spend their time at the home and what activities to be involved in. They are encouraged and supported to maintain contact with friends and relations. EVIDENCE: All the service users interviewed felt that the home met their social and spiritual needs. They said that they had plenty of choice over how they spent their time at the home, for example all the care plans contained information about their preferred daily routines. The service users said that staff try their best to accommodate this. Some service users were in their bedrooms on the day of the inspection and they said that they preferred this and they could go to the lounges when they wanted. All the service users interviewed said that their relatives could visit at any time and that their relatives were made welcome. One relative interviewed confirmed this and said that the home is very good about keeping her informed of her relative’s progress. All said that they could get up and go to bed when they wished and that they never had to wait long for assistance if they needed it. All felt that there were enough activities and there was an activities programme on display. They said there were quizzes, games, concerts and trips out. Regular religious services are held and a number of the service users stressed the importance of having their spiritual needs addressed. All the service users felt that there was plenty of Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 12 food provided and that drinks were always available. Most of the service users were happy with the variety and quality of food provided, however some felt that the quality was not as good with contract caterers in place. No requirements are made in this report regarding the food as service users said that the food had improved recently after they were consulted about this. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 The home has a formal complaints system and service users felt they were encouraged to make comments or raise concerns about the service. EVIDENCE: The home had a formal complaints procedure which included timescales for a response from the owners. It advised service users and their relatives that they could contact the Commission for Social Care Inspection at anytime with any complaints. No formal complaints had been received by the Commission for Social Care Inspection since the last inspection. All service users said they would have no hesitation raising concerns and several stressed that they were encouraged to raise concerns, for example, at the monthly service users’ meetings. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 23 24 26 Service users live in a comfortable and safe environment. The home was generally well-maintained and clean. EVIDENCE: On the day of the inspection the home was clean, in the main reasonably decorated and maintained. There was appropriate sitting, recreational and dining space. There were a number of small lounges and sitting areas where service users could sit quietly if they wished. There were sufficient rooms for a variety of activities to take place and service users can see visitors in private in their own rooms. The dining areas are large enough to cater for all service users. Seven bedrooms seen were highly personalised. All the service users said that they were happy with their personal space and could access it at all times. Carpets, bedding and curtains were clean and in a good condition. There was sufficient bathing, toilet and washing facilities. During the inspection it was noted that one fire exit was blocked by items being stored in the hallway and under the stairs. These were cleared during the inspection. Previous reports Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 15 indicated that the home needed to redecorate particular areas of the home and this work was underway. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 Staff were employed in sufficient numbers. EVIDENCE: Two weeks rotas were seen which showed that staffing levels were being maintained. Service users interviewed stated that they felt there were always sufficient staff on duty and that extra cover was provided when necessary. There are three waking night staff at the home. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 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 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 32 38 There is a suitably qualified and experienced manager who appears to promote an open atmosphere that encourages service users to be involved in the running of the home. The home needs to ensure that the building is kept safe for service users. EVIDENCE: The current manager has applied to be registered with the Commission for Social Care Inspection. She has nursing and social care qualifications and is experienced in senior management. Service users spoken with were very positive about her attitude towards them and said that they would have no hesitation about making complaints or reporting any concerns to her. As noted above, during the inspection it was found that one fire exit was blocked by items being stored in the hallway and under the stairs. This was cleared immediately on the day. Potentially hazardous cleaning materials were also found unattended on one corridor. Fire alarm testing records had been Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 18 completed on a regular basis. Fire training had taken place but not all staff were recorded as having had training in the previous 12 months; similarly manual handling training records did not show that all staff had received updated training. It was noted that the home does have in-house trainers who can deliver this training. Hawthorns (The) DS0000020007.V252903.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 Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 3 11 3 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 X 2 3 X X 3 3 X 3 STAFFING Standard No Score 27 3 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 X X X X X 2 Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 20 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP3 Regulation 12 (1) (b) Requirement Assessment information must fully cover standard 3.3 and include all of the required information. From inspection report 06/09/04. Changes in service users’ needs must be identified in reviews and the ‘Personal Care Plan’ amended accordingly. The damaged wallpaper in the ground floor lounge must be repaired. From inspection report 08.04.04. The damaged paintwork in the corridor areas must be repaired and redecorated. From inspection report 08.04.04. The registered person must ensure that the service user’s plan sets out in detail the action which needs to be taken by care staff to ensure that all aspects of the health, personal and social care needs of the service users are met. From inspection report 06.09.04. All staff must have updated manual handling training on a regular basis. DS0000020007.V252903.R01.S.doc Timescale for action 30/12/05 2 OP7 15 (1) 30/12/05 3 OP23 23 30/01/06 4 OP22 23 30/01/06 5 OP7 15 (1) 30/01/06 6 OP38 13 (5) 30/11/05 Hawthorns (The) Version 5.0 Page 21 7 8 9 10 OP38 OP38 OP22 OP38 23 (2) (d) and (e) 13 (4) (a) (c) 13 (4) (a) 13 (4) (a) (c) All staff must have updated fire training on a regular basis. Cleaning materials must be kept locked away when not in use. Suitable storage space must be provided for wheelchairs, hoists, mobility scooters etc. The manager must check regularly to ensure that all fire exits are kept clear. 30/11/05 30/09/05 30/03/06 30/09/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard OP7 OP38 Good Practice Recommendations The manager must check the care plans to ensure that the language used to describe service users’ behaviour is appropriate. A record should be kept which shows when staff are due to have updated statutory training. Hawthorns (The) DS0000020007.V252903.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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) DS0000020007.V252903.R01.S.doc Version 5.0 Page 23 - 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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