Care Home: Hawthorn House

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What the care home does well People are well assessed on entry to the home, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. They are protected from possible harm, due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication very well and staff are trained in medication administration. People experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. They are encouraged to maintain contact with family members and friends and enjoy visits from them any time of the day, and they are encouraged to exercise choice and control over their lives. People enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. They are confident their complaints will be listened to and acted upon. People are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service`s policies, procedures and practice under the safeguarding adults systems. They experience a safe, clean and well-maintained environment. A sufficient number of care staff work in the home on each shift to meet the assessed and changing needs of people. The manager runs the service in the best interests of the people that live there, safeguards their financial interests, and maintains their health, safety and welfare. The home is well protected in respect of health and safety and fire precautions etc. What has improved since the last inspection? The service now records returned unused medication. It also makes sure a GP signature or that of two staff is obtained when administration instruction changes take place. The service now makes sure staff receive safeguarding adults training or awareness shortly after they begin working in the home. This now needs to be done annually. The service has now completed the requirements made by the fire prevention officer at the last visit made to the home. The service now has liquid soap dispensers and paper hand towels available for use in public areas, as recommended by the environmental health department. The service has improved its recruitment and selection practices by following the procedures more closely and making sure new staff have a minimum of a preliminary security check and then a full security check before they begin working in the home. Staff supervision has improved and staff are being seen and given the opportunity to discuss issues every two months now. What the care home could do better: The service could make sure the dates of staff security clearances are obtained and kept with the person`s name and their clearance identification number, so people are confident safe staff are caring for them. The service could make sure a legionella bacteria sample test is carried out on the hot water storage tank, every three years, so people are confident they are protected from harm of infection. The service could also make sure staff sign the record of the fire safety drill after attending it as evidence they were present, so people are confident they are protected from the risk of harm from fire. CARE HOMES FOR OLDER PEOPLE Hawthorn House 19 Ketwell Lane Hedon East Yorkshire HU12 8BW Lead Inspector Janet Lamb Key Unannounced Inspection 20th August 2008 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 Hawthorn House DS0000036095.V370795.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. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorn House Address 19 Ketwell Lane Hedon East Yorkshire HU12 8BW 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) 01482 898425 F/P01482 898425 Claire Louise Johnson Charles William Johnson Claire Louise Johnson Care Home 22 Category(ies) of Dementia - over 65 years of age (22), Old age, registration, with number not falling within any other category (22) of places Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st August 2007 Brief Description of the Service: Hawthorn House is a privately owned residential home that is close to the town centre of Hedon. The home is close to the main road and has good access to public transport. There is also a minibus available to take service users on trips out. The home is registered for 22 people of either gender over the age of sixty-five years. It also provides for those people who may have dementia. Last year the home had an extension built to the rear and the accommodation provided is now in one shared room and twenty single rooms, seventeen of these having en-suite facilities. There are two communal lounges, a separate dining room and a conservatory. All areas of the home are accessible to people via the provision of a stair lift and a passenger lift. The latter was installed at the same time the extension was built. The home is well maintained and there is a car park at the front of the building and a garden to the rear. The weekly charges are between £350.00 and £396.50 and there are additional charges for hairdressing, chiropody, toiletries, bingo, newspapers and magazines and in some cases continence aids. This information was provided by the provider/manager on the day of the site visit. Information is available about the service through the ‘statement of purpose’ and ‘service user guide,’ which are posted in the home’s reception area or can be obtained from the provide/manager on request. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3-star. This means the people who use this service experience excellent quality outcomes. The Key Inspection of Hawthorn House has taken place over a period of time and involved sending an ‘annual quality assurance assessment’ (AQAA) document to the home in June 2008 requesting information about people and their family members, and the health care professionals that attend them, as well as asking for numerical data held in the home. We received the requested information in July 2008 and survey questionnaires were then issued to a selected number of people and their relatives. The information obtained from surveys and information already known from having had contact with the home since the last key inspection, was used to suggest what it must be like living there. On 20 August 2008 Janet Lamb, Regulation Inspector and Mr Peter Southon, Expert by Experience, visited the home to test out the suggestions made and to interview people, staff, visitors and the home manager. Some documents were viewed with permission from those people they concerned, and some records were also looked at. Parts of the premises were inspected and some practices were observed. Comments of the visiting Expert by Experience: I arrived at Hawthorn House at about 10:15 and was immediately impressed by the friendly welcome and the atmosphere of a mixture of calm and ‘resident’ activity in the dining room. I asked to speak to the owner/manager who explained the history of the home and described the type of problems, which people have. What the service does well: People are well assessed on entry to the home, having been given good information on what the home is like and what to expect, and they are provided with a good care plan for staff to follow. They are very well supported with health care that meets their needs and their expectations. They are protected from possible harm, due to taking the wrong medication, because they have their medication handled by the staff in the home, and the staff follow robust practices and procedures. The service handles medication very well and staff are trained in medication administration. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 6 People experience good levels of privacy, have their dignity maintained, and their right to make decisions is respected. They are encouraged to maintain contact with family members and friends and enjoy visits from them any time of the day, and they are encouraged to exercise choice and control over their lives. People enjoy good food, which matches their expectations and preferences, but also offers a satisfactory level of nutrition. They are confident their complaints will be listened to and acted upon. People are protected from abuse by robust recruitment and selection procedures and practices, as well as by the service’s policies, procedures and practice under the safeguarding adults systems. They experience a safe, clean and well-maintained environment. A sufficient number of care staff work in the home on each shift to meet the assessed and changing needs of people. The manager runs the service in the best interests of the people that live there, safeguards their financial interests, and maintains their health, safety and welfare. The home is well protected in respect of health and safety and fire precautions etc. What has improved since the last inspection? The service now records returned unused medication. It also makes sure a GP signature or that of two staff is obtained when administration instruction changes take place. The service now makes sure staff receive safeguarding adults training or awareness shortly after they begin working in the home. This now needs to be done annually. The service has now completed the requirements made by the fire prevention officer at the last visit made to the home. The service now has liquid soap dispensers and paper hand towels available for use in public areas, as recommended by the environmental health department. The service has improved its recruitment and selection practices by following the procedures more closely and making sure new staff have a minimum of a preliminary security check and then a full security check before they begin working in the home. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 7 Staff supervision has improved and staff are being seen and given the opportunity to discuss issues every two months now. 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 summary of this inspection report can be made available in other formats on request. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 8 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 Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3 and 6. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have their individual and diverse needs well assessed so they are confident needs will be met. They receive good written information in the form of a statement of purpose and a service users guide. People have wellconstructed contracts of residence and a statement of terms and conditions so they can decide if the home is the right place for them. EVIDENCE: People spoken to say they can remember the assessment process they took part in and that they are aware of their care files and documents. People are Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 10 positive about having had their needs considered and say they are well addressed by the home and the staff. Files viewed with people’s permission evidence that assessments are completed and include individuals’ diverse needs. Assessments cover eleven areas of need: personal self-help skills, domestic self-help skills, shopping/money ability, communication, health, mobility, social contact, daily routine, past history, relationship needs, mental state and cognition. Some of these areas are broken down into detailed needs; e.g. personal self-help has sections on dressing, choices, continence, diet etc. There are also copies of the placing local authority community care assessment documents held in separate archived files for people. Additional documents seen include contracts of residence for private payers, placing local authority contracts, and copies of letters under regulation 14 (1)(d) to people declaring their assessed needs can be met. The home does not provide any intermediate care services and therefore standard 6 is not applicable. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service receive excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have their health and social care needs very well documented in care plans, so they are confident all their needs will be met. They have very good opportunities to self-medicate or their medication needs are very well managed, and they enjoy excellent levels of privacy and their dignity is well maintained, so they are confident their overall quality of life is excellent. EVIDENCE: People spoken to are aware of their care plan documents in place, and they say personal care needs are met in a way they want them to be met. One person said, “Any help you need you get it straight away. We just press the call bell and staff come.” A relative said, “We had a review of mum’s care plan Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 12 only last week and we are very satisfied with everything. This is a nice place for relatives to visit as well as for people like mum to live.” Care plans seen with permission from two people evidence that they are in place and used and cover personal and social care needs, communication, personal hygiene and continence, daily routine, past history including a separate form with medical history, religious or cultural needs, hobbies and social interests. A moving and handling risk assessment is undertaken for each person and other risks are also detailed on this document and include dressing/undressing, going out of the building, personal limitations or communication difficulties etc. Health care needs also assessed and recorded in with general care plans. Other records include signed ‘wishes for arrangements on death,’ visits from GP or other health care professionals, weight charts if needed and a list of medication being taken. Key workers or the manager reviews care plans monthly and every 6 months in line with the placing local authority recommendations. The homes last reviews were dated January 2008 and May 2008. The local authority ‘Fairer Access to Care Services,’ (FACS) review documents seen were dated 15/10/07 and 13/08/08. The medication systems in place and used are based on a written policy and procedure. There is also a procedure for self-medication. The home currently uses Boots Manrex monitored dosage system. There are medication administration record sheets (MAR sheets) in place that are completed satisfactorily and medication storage is appropriate. There are no controlled drugs administered at the moment. Medication administration training is provided through Boots Chemists or via the Hull City Council training diary, though recent attempts to book any training with the Council have not been successful due to being fully booked. People spoken to about their medication said, “My medication is in the cabinet, I don’t want to look after it,” and “I have diabetes and my tablets have been changed, but I like the way they are given to me.” No one expressed any strong desire to keep control of the medication they have prescribed. Files seen for staff, with permission, show those giving out medicines are usually trained seniors, though one has not done a course since 2004. Because of this training up dates are planned for 10th and 24th September 2008 and when completed will bring all seniors back in line with required current practice on handling medication. Recommendations made at the last inspection were discussed with the manager. There is now a returns record of all medicines sent back to the pharmacist and a signature is obtained of the person collecting it. The home is also now obtaining a GP or two staff Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 13 signatures when administration instructions have changed. One such entry by a GP and dated 04/08/08 was seen as evidence. Privacy and dignity was discussed with the manager and staff and there is a policy and procedure in place to promote good practice. People spoken to said, “I don’t need any personal care, but I’m sure it would be done in private,” and “I prefer to stay in my room, no one stops me and they knock before coming in. Any help is given here. I have my own telephone and can speak to my family in private anytime.” Observations made on the day of the site visit show staff to be very discreet with such as offering assistance with use of the toilet for example. They address people how they choose to be addressed, and offer assistance with such as eating in a sensitive manner. Staff are very understanding of people’s needs and their moods. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People enjoy flexible routines, contact with relatives and friends and have very good opportunities to be self-determining. They have excellent opportunities to engage in pastimes and for going out. They enjoy home-cooked food and contribute to menu planning and choices. This means people are confident their daily lives and many of their social activities meet their expectations. EVIDENCE: People spoken to say they enjoy a variety of pastimes and activities taken from a weekly plan and facilitated by a designated activities coordinator. Pastimes enjoyed include trips out, knitting, sewing, idle chatter, garden parties, dominoes, bingo, television, quizzes, and basket making. Entertainers also visit the home each month to sing, and people make use of a village library, Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 15 which is nearby or subscribe to the talking book scheme run by the Royal National Institute for the Blind (RNIB). People say they have good contact with family and friends. Visitors are frequent and one spoken to says they enjoy coming to the home. There are no restrictions on visiting. People receive their visitors in bedrooms if they wish to and we observed this when we interviewed one person and her daughter in her room. They both confirm people can handle her own finances and make all the choices and decisions they want to. Information received from the manager shows some people have solicitors that handle their finances for them, while nine people have small amounts of money held in safekeeping and this is properly recorded and accounted on individual record sheets. A check carried out on two people’s money showed systems to be well used and correct. All records are held under the Data Protection Act 1998 regulations. People are fully consulted about food and menu choices. The cook puts together the menus, after seeking people’s views in meetings and their individual choices and likes are listed in the kitchen. All comments received on food provision were positive from everyone. Menus were seen, the kitchen was only briefly seen through the door/window, but food seen looked nutritious and appetising and it smelled delicious. All meals are home-cooked from fresh ingredients. There are usually two sittings for lunch, so that those needing more assistance are given it. Staff wear tabards, sit with people, and assist them sensitively. There are tablecloths on the tables that are decorated with a centrepiece, juice is provided, and specialist tools and crockery are available where needed, etc. All of this is evidence through observation and via diary notes, menus, resident meetings and records etc. Comments of the visiting Expert by Experience: The home has some twenty-five people being cared for either permanently or on a day care basis, with about a third having a visual impairment or blindness. I explained that I was particularly interested to see the type of activities which were available as my experience indicated that often people, especially those with dementia, needed activity to stop them being bored and hence upset/agitated. The manager explained that most of the people in the home had been day care visitors in the past, some for a long time so she had had the opportunity to find out what each of them liked to do, could do etc., and recorded this in the person’s care plan. She was therefore able to, wherever possible, fit each person into one of the many activities, which are on going. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 16 The home has an activities organiser who provides a craft day every week, which includes basket making, knitting and similar pastimes. Two entertainers visit the home each month to sing and entertain with organ music. I viewed two care plans, which indicated people’s likes, hobbies and interests. The staff also arrange other activities such as quizzes, parties; I saw a cake in readiness for someone’s forthcoming birthday party. A local vicar visits each month to hold a service in the home. The home has a mini bus, which the provider’s husband or another qualified driver uses to take people out on trips/excursions. A large television was available in one lounge but it was not on. This was a good sign and later on when talking to the residents I could see that there were more interesting things to do. Whilst I was there I heard, in another lounge, a member of staff questioning several people on what else they would like to do for future activities. Several people already make use of a village library, which is nearby or make use of the talking book scheme with the RNIB. I spoke to one person, some 95 years of age, who liked walking and was deeply engrossed in a book on mountain climbing. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People make use of the formal complaint system or are aware they can do at any time, so they are confident their concerns are listened to and usually dealt with effectively and efficiently. They also experience good promotion and protection of their welfare and so feel confident the systems in place to protect them are robust. EVIDENCE: There are appropriate policies and procedures in place for handling complaints and records of complaints are satisfactorily held. People say they have no need to complain, but would speak up if necessary and are usually satisfied with any action quickly taken when they do. Complaints do not usually reach this stage, as people voice their views and needs and the manager listens and responds. People say they know how to formally complain, have written information on the process and would find it easy to discuss any issues with the manager. There are no recorded complaints. Staff have a health attitude to people making grumbles known and demonstrate they know the procedures to follow. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 18 There are policies and procedures in place for handling safeguarding issues. A requirement made at the last inspection for all staff to be trained in safeguarding adults’ issues has now been dealt with and all staff have done some kind of training or awareness course. The manager, deputy manager, assistant manager and coordinator have all done the manager’s safeguarding adults course with Hull & East Riding Safeguarding Adults Board. Information obtained from the board has then been cascaded down to everyone in an inhouse training session and individuals’ understanding has been checked in supervision. Staff training in this area needs to be updated annually and evidenced. The new induction booklet for new staff to work through now has full details on safeguarding procedures and responsibilities. Staff confirm their training and understanding in interview and files show details. Comments of the visiting Expert by Experience: The home has a complaint system, but no one has yet seen the need to use it. I spent at least an hour speaking to people; about 15 of them, some were busy making baskets some knitting or unpicking wool for those knitting and some were sitting and chatting with other people. Every one that I spoke to was happy or very happy with their home, the food and the staff. They were pleased to say how much they liked Hawthorne House. I spoke to several members of staff who you could see liked their job and knew the people they cared for very well. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. People who use the service experience good quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People have a well-maintained, safe, clean and comfortable environment in which to live, so they are confident they have a good home. EVIDENCE: The home is suitable for its stated purpose of providing care and accommodation to older people. It is safe, very well maintained and decorated, clean and comfortable. It meets people’s needs very well. There are two lounges, a conservatory and dining room. Individual bedrooms are pleasant and highly personalised. There is a programme of routine Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 20 maintenance and the house is very well kept inside and out. The rear garden has been landscaped in the last year and now has a water fountain with night lighting and provides a very lovely setting. People say they are very satisfied with the environment, their rooms and cleanliness and with the privacy they are able to achieve. The fire and environmental health departments do not visit as regularly as they used to, but as far as is known the requirements of both sets of regulations are being followed. We discussed last year’s fire prevention officer’s requirement, as highlighted in last year’s inspection report, to have intumescent strips fitted into all fire safety doors. This work is now complete and the fire officer has been informed. The home now has liquid soap dispensers and paper towels for washing/drying of hands in all of the public facilities, and therefore meets the recommendation made last year. The laundry meets the requirements of the standard and of the Water Supply (Water Fittings) Regulations 1999. Comments of the visiting Expert by Experience: The home has two lounges plus a sunny conservatory overlooking the back garden. The assistant manager showed me a selection of the single bedrooms, which were all well decorated, with bathrooms, and containing a good selection of people’s things in them. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People are cared for by well-recruited, well-trained, confident and skilled staff in satisfactory numbers to meet their needs, so they enjoy an excellent service of care. EVIDENCE: There are sufficient numbers of staff on duty through out the day and night to meet the needs of people. Rosters seen and staff testimony evidence this. People are satisfied with the levels of care and support they receive and say they like the staff, as staff are reliable, thoughtful and conscientious. People say they do not have to wait long when they seek assistance through the home’s call bell system. Of the 23 care staff working in the home 12 has achieved the NVQ level 2 award and some are doing level 3. This is sufficient to meet 53 with the award, and efforts need to continue, but this is not a problem as staff are Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 22 reported to be keen. One wants to do the NVQ level 4 Registered Manager’s Award, while others are to enrol on level 3 as soon as they can. Recruitment and selection procedures have been followed more rigorously since the last key inspection. Files seen for two long-standing staff show the necessary checks and identity verification requirements have been met. Discussion about current practice shows staff now only start work when their full security check has been received. The manager is recommended to obtain and keep the dates of staff CRB checks, along with their clearance identification numbers, as received from the ‘umbrella body’ it uses. Training and development needs are identified in supervision and a general plan is devised for the year to show what is needed and when it shall take place. This is then completed throughout the year and kept as the record of training. Mandatory courses include moving and handling, infection control, first aid, safeguarding adults, medication administration and fire safety. Other courses include Parkinson’s disease and dementia etc. Staff confirm this in interview and records seen in files evidence the training done. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. People who use the service experience excellent quality outcomes in this area. This judgement has been made using evidence gathered both during and before the visit to the service. People live in a home that is very well run and in their best interests, where very good systems are in place to determine the quality of the service. Peoples financial interests are generally not the responsibility of the home, but where money is held for them very good systems are in place. Peoples’ health, safety and welfare are very well promoted and protected, so they are confident they are safe and well cared for. Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 24 EVIDENCE: The manager is also the registered provider. She has the NVQ level 4 in Care and Management and many years experience working with older people. There are clear lines of accountability within the home as there is a deputy manager, an assistant officer and care staff. There are job descriptions available for the manager identifying the role and responsibilities of the post, as well as for the other staff. There is a quality assurance system in place, but this was not fully assessed. Information remains the same as at last year’s key inspection. The home has also been awarded Parts 1 and 2 of the East Riding of Yorkshire Council Social Services Quality Development scheme. The home seeks the views of service users via meetings, quality surveys and reviews. Other stakeholders’ views are also sought including relatives and friends. There is a clear development plan in place and an annual review is produced. The home has financial policies and procedures to ensure people have their financial interests safeguarded. Written records in the form of accounting sheets showing transactions in/out, dates, signatures, balances etc. were checked for two individuals. These were up to date and correct. The home promotes independence and the manager confirmed that all of the residents or their families have control over their own finances. People say they are satisfied with the individual arrangements in place. Supervision of staff was briefly discussed with the manager, and is now carried out more regularly. Staff confirm this in interview and staff files evidence that supervision is every two months. The home has policies and procedures available for safe working practices. The home has up to date maintenance certificates available. These include electrical installations, portable appliance testing, hoists, fire alarm and emergency lighting certificates, as well as checks on the hot water storage tank and temperature control checks on bathroom and bedroom hot water outlets. It is recommended that there is a three yearly legionella bacteria sample test done on the hot water storage tank. There are risk assessments in place for the premises and a fire risk assessment that is reviewed on an annual basis. Records are maintained of fire safety system checks and fire safety drills held. It is recommended that staff sign fire drill records after attending drills as evidence of their presence. Cleaning products are stored and used safely according to their safety instructions under the Control of Substances Hazardous to Health Regulations Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 25 1998. Personal protective equipment is available to staff, as they testify and as observed. Comments of the visiting Expert by Experience: I was very impressed with Hawthorne House. This is obviously the life of the provider/manager, which has been absorbed by her staff with the result that people living there have a ‘real home.’ Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 26 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 N/A HEALTH AND PERSONAL CARE Standard No Score 7 4 8 4 9 4 10 4 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 4 14 4 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 3 29 3 30 4 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 4 X 3 X X 3 Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 27 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. 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 Refer to Standard OP29 Good Practice Recommendations The registered provider should make sure the dates of CRB clearances are obtained and kept with the person’s name and their clearance identification number, so people are confident safe staff are caring for them. The registered provider should make sure a legionella bacteria sample test is carried out on the hot water storage tank, every three years, so people are confident they are protected from harm of infection. The registered provider should make sure staff sign the record of the fire safety drill after attending it as evidence they were present, so people are confident they are protected from the risk of harm from fire. 2 OP38 3 OP38 Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB 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. Extracts may not be used or reproduced without the express permission of CSCI Hawthorn House DS0000036095.V370795.R01.S.doc Version 5.2 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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