Care Home: Hawthorne Care Home

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

What the care home does well We found that the home is clean and well maintained with various day areas both inside and outside of the home that people can safely access. We found that the manager makes sure that people receive a thorough assessment of their needs before they come to stay at the home which makes sure that there are suitable facilities and staff skills to manage people’s needs from the outset of their admission. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 People have their health and personal care planned in consultation with them or their advocate and have regular opportunities to review these plans to make sure things are working well. Medicines are managed well which ensures that people receive their prescribed treatment safely. There is a robust recruitment policy and staff training programme that ensures people are in safe hands from a trained staff team. Complaints and concerns are handled well and people get opportunities to raise issues before they need to complain. Relatives spoken to told us that “the staff are very good and care about people” What has improved since the last inspection? The manager has addressed all of our requirements that we set at the last inspection, improving on care planning, planning for the equality and diversity needs of people from minority ethnic communities, commencing resident meetings and implementing training for staff in the new Mental Capacity Act and associated deprivation of liberty safeguards. What the care home could do better: The provider must consult with the Fire Officer about the timescale for complying with the improvement notice that was served in May 2009 to fit automatic closure devices to bedroom doors to ensure the health and safety of people using the service. We have made 6 recommendations for the manager to consider as part of the continuous development and improvements of the service. Key inspection report CARE HOMES FOR OLDER PEOPLE Hawthorne Care Home School Walk Bestwood Village Nottingham NG6 8UU Lead Inspector Mary O`Loughlin Key Unannounced Inspection 23rd July 2009 10:00 DS0000026443.V376713.R01.S.do c Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care homes for older people can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorne Care Home Address School Walk Bestwood Village Nottingham NG6 8UU 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) 0115 9770331 0115 9770332 njh1963@yahoo.co.uk 1st Care Limited Mrs Christine Anne Walters Care Home 36 Category(ies) of Dementia (36), Old age, not falling within any registration, with number other category (36) of places Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following categories of service only: Care Home with nursing - Code N to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old age, not falling within any other category - Code OP Dementia - Code DE The maximum number of service users who can be accommodated is 36 7th July 2008 2. Date of last inspection Brief Description of the Service: Originally constructed as the village Rectory, Hawthorne Care Home has been extended and developed to provide accommodation and care for up to 36 people over the age of 65 years. The home can admit up to 36 people whose primary care needs are dementia. Situated to the North of Nottingham City centre in Bestwood Village, Hawthorne Care Home has thirty single bedrooms and three double bedrooms. A passenger lift provides access to the first floor. The home sits in its own grounds and is close to local shops, public houses and local transport links. There is a car park to the front of the building. The statement of purpose, service user guide and a copy of the last report are in the reception area, opposite the manager’s office if people who live at the service, relatives or visitors wish to see them. The current fees charged at the home range from £356 to £380 per week and people who live at the service are required to pay additional costs for hairdressing, chiropody, trips out, personal toiletries and clothes and newspapers. Hawthorne Care Home DS0000026443.V376713.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 2 star which means that people who use this service receive good outcomes. This report has been written using accumulated evidence gathered before and during the inspection, including information obtained from 4 Have Your Say staff surveys completed by staff, 6 surveys completed by residents and 2 surveys completed by health professionals. The Annual Quality Assurance Assessment (AQAA), issued by the Care Quality Commission was returned completed by the registered manager. This self-assessment gives providers the opportunity to inform us about their service and how well they are performing. We (CQC) also assessed the outcomes for the people living at the home against the Key Lines of Regulatory Assessment (KLORA). During the inspection we looked at the records of 3 people and used a method we call case tracking that examines the way people are supported with their needs at the home. We spoke to key staff involved in peoples care and spoke to the people receiving the service and their relatives, visiting them in their private rooms and viewing the facilities and services available to them. Other issues such as the management of the home and health and safety were looked at to form an opinion of how the home is run. We looked at the information within the Environmental Health Officers report of 25/05/08, the Nottingham County Council Safeguarding Adults investigation report of 18/03/09 and their Nutritional Balance Team audit report, and also the local Primary Care Team Quality Monitoring Officers report of 02/06/09 and have included some of their findings within this report. What the service does well: We found that the home is clean and well maintained with various day areas both inside and outside of the home that people can safely access. We found that the manager makes sure that people receive a thorough assessment of their needs before they come to stay at the home which makes sure that there are suitable facilities and staff skills to manage people’s needs from the outset of their admission. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 6 People have their health and personal care planned in consultation with them or their advocate and have regular opportunities to review these plans to make sure things are working well. Medicines are managed well which ensures that people receive their prescribed treatment safely. There is a robust recruitment policy and staff training programme that ensures people are in safe hands from a trained staff team. Complaints and concerns are handled well and people get opportunities to raise issues before they need to complain. Relatives spoken to told us that “the staff are very good and care about people” What has improved since the last inspection? What they could do better: If you want to know what action the person responsible for this care home is Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 7 taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Hawthorne Care Home DS0000026443.V376713.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 Hawthorne Care Home DS0000026443.V376713.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 3-6 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who want to live at the service have the information they need to make an informed decision about moving into the home. Their needs are assessed so they can be assured that these can be met at the service. Intermediate care is not provided by the home. EVIDENCE: Since our last inspection the home have applied for and successfully registered to accommodate up to 36 people who have Dementia as their primary need. To support this major change to their registration the manager ensured that the staff team have undertaken dementia awareness training, which covered the different types of dementia, the treatment of it, people’s rights and the staff Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 10 responsibilities to those with dementia to ensure that they had the appropriate skills to care for them. We know from our registration visit to the home in September 2008 that there is a suitable and updated statement of purpose and a guide to the home which now gives people a clearer idea of what the service provides, especially for people who may have Dementia. This should help them make an informed decision when choosing whether to live at Hawthorne. Our previous key inspections have evidenced that there was a track record of ensuring that people who want to live at the home receive a proper assessment by trained staff to determine how people need and wish to be supported with their health and personal care. This inspection found that the manager only makes the decision to offer people a place at the home when they have made sure that the service can safely and appropriately manage the person’s care. We spoke with a relative of a person who had recently been admitted to the home and were told how the staff had supported both husband and wife during the process of coming to stay. We were told how the staff had been “absolutely wonderful” “They supported me, always explained things, took time and were so caring” “My Husband has improved, he eats well and we can still share meals together in private” We looked at how staff record the needs of people who are new to the home and found that they had written full and clear care plans to make sure that staff knew exactly how to support the person Hawthorne Care Home DS0000026443.V376713.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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 7-8-9-10 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to be treated with respect, have their health needs met and have a care plan that describes their wishes in how they are to be supported. People can also expect to receive their medicines safely by appropriately trained staff. EVIDENCE: Since the appointment of the manager last year there has been continuous improvement in how care is planned and managed, staff have received training to provide them with a better understanding of how to plan peoples care effectively and in a more person centred way. We saw how 3 people that we case tracked had a full and clear record of their needs and how staff were to support them in accordance with their wishes. The person or their advocate Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 12 was consulted each month on how well care plans were working and if they needed to change. The manager has also delegated lead roles to trained nurses as links in infection control, continence and tissue viability which enables them to deliver safe, up to date and evidenced based care. The Primary Care Trust undertook a recent quality visit to the home in June 2009 and their report shows that care practices minimise the risk of people developing pressure sores and people requiring help with mobility are supported to be as independent as possible. All 6 people we surveyed who live at the home told us they always receive the care and medical support they need. 2 external health care professionals have told us that that peoples social and health care needs are always properly monitored, reviewed and met by the care service. And people receive the support to administer their medicines or have it managed correctly. They felt people’s dignity was always respected. The requirements we set at our last inspection have been addressed, there is now appropriate information recorded for people of different cultures to ensure they receive the care they need. There is also better understanding within the staff team about new legislation around people’s capacity to consent to treatment, all the staff have received training in this area and more is planned. Some care plans we looked at included information on people’s capacity to make decisions and the manager is continuing to work and develop this area to make sure that people who lack mental capacity are supported to make decisions wherever possible and that care and treatment is provided in their best interest. The Commission undertook a pharmacy inspection in September 2008 and found the practices around medicines to be safely managed. During this inspection we saw how the manager has worked very hard developing auditing systems to ensure that medicine is always handled safely. Practices have improved following our recommendations to obtain up to date medicine reference books, better monitoring of cold storage medicines and agreements from individual Doctors for the use of any homely remedies. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 13 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 12-13-14-15 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to have regular contact with their family and the community; they will receive a well balanced diet and adequate hydration to maintain their well being. EVIDENCE: Our last inspection found that there were lots of different activities for people who live at the service to get involved with, both group ones and individual. There are activities which are targeted at people with Dementia as well as those people who are more able and the people who live at the service can choose whether to be involved or not. People who live at the home told us that their relatives can visit them at anytime and there are places where they can talk with them in private. The manager told us in the AQAA that they have two activity coordinators (job sharing) providing structured activities five days a week. They have introduced Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 14 more visiting entertainments including twice monthly visiting church services, mobile library and a visiting pet therapy, this enables people to maintain links with the community. This inspection found that people continue to be offered opportunities that reflect their preferences and choices. Relatives told us how they could visit when they wished and were able to sit and have meals with their relative when visiting. We saw the report from Nottingham County Council Nutritional Balance Team from their visit in June 2009 which stated they were impressed with the standards of hygiene and cleanliness in the kitchen. We also saw the report from the Primary Care Trust in June 2009 that concludes people are provided with a well balanced diet and adequate hydration to optimise their well being. All 3 people we case tracked had been regularly assessed for any nutritional risk and were weighed each month. There was evidence that when people had swallowing problems they were accessing the NHS specialist services for this and the staff maintained robust recording of any feeding regimes and oral cleansing. Hydration records showed that people received drinks regularly. We saw evidence that the staff team have received training in dementia and nutrition this year. Following recommendations from a safeguarding investigation report undertaken by Nottingham County Council they are now recording all meals provided and anyone requiring nutritional support has a separate record of all meals provided. Intake charts record how much fluid is given to people each day but slippage with totalling the 24hr intake was seen which would not always ensure staff were alerted to any reduced intake quickly. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 15 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 16-18 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service are listened to and concerns are taken seriously and dealt with appropriately. EVIDENCE: People have access to a robust complaint procedure, displayed in different areas of the home it explains the process for anyone that wishes to make a complaint. People we surveyed and relatives spoken with told us they felt safe, listened to and taken seriously. The manager has told us in the AQAA that she has dealt with 2 complaints in the last year and holds records of each investigation. She has improved on consultation with people who live at the home by improved care planning and opportunities for people to have their say about the service through satisfaction surveys and regular meetings. The staff team have received training on how to protect vulnerable people from abuse in the last year and the manager has updated the policies to reflect up Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 16 to date guidance on how to manage any suspicion of abuse. The recruitment procedure also demonstrates that the manager ensures robust procedures are followed to prevent anyone unsuitable from working in the home. The commission have received information from a relative who had been dissatisfied with how the home had dealt with a complaint, (the complaint was made prior to the appointment of the present manager) this was referred to the Local Authority and subsequently an investigation was undertaken by Nottingham County Council. The results reflected evidence of poor practice and made recommendations to address the issues. This inspection found that the recommendations regarding diet and fluid records have been addressed. We have not received any other concerns or complaints about the service and the manager has appropriately informed us of a safeguarding adult alert where action was taken to safeguard people using the service. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 17 Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 18 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 19-26 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment provides suitable accommodation for the categories of people for whom the home is registered. EVIDENCE: We undertook a visit to the home as part of our methodology when the service applied to vary their registration with us in September 2008. We found that an additional sitting area has been created as well as the existing large lounge/dining room, to provide a quiet or sensory area. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 19 An alarm system was in place on all exterior doors and an updated risk assessment of the premises had been undertaken to take into account accommodating people having dementia. Appropriate signage was being placed on doors and the manager informed the inspector that memory boards of residents were going to be placed in their bedrooms if it was their wish. Corridors were being decorated and carpeted to provide distinction between areas of the home. The manager stated that corridors would be made less institutional by placing flowers and soft furnishings at points throughout. An enclosed garden area was accessible from the main lounge and this area had had handrails installed and steps had been replaced by ramps where necessary. During this inspection we saw the rooms of 3 people that we case tracked and found that they had appropriate facilities to meet their needs. Each room had controlled hot water temperature to protect people from any risk to their safety and all radiators were guarded. The Primary Care Trust quality report told us that the home manager is in the process of reviewing the homes infection control policy using the Department of Health Guidance and Primary Care Trust guidance to ensure it reflects best practice and protects people from any spread of infection. We found that staff have received training in infection control practices and they have access to suitable protective equipment and hand disinfection to ensure infection is controlled. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 20 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 27-28-29-30 People using the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use this service can expect to be supported by adequate numbers of correctly recruited and well-trained staff. EVIDENCE: The manager has focused on ensuring the staff team have been trained in how to promote people’s dignity at all times, they have appointed a dignity champion as part of the Department of Health’s campaign to put dignity at the heart of care services. Posters are displayed around the home to raise awareness of the issues. The manager has allocated specific staff to meet the identified cultural needs of one person at the home, ‘matching’ the person’s diverse needs showing a person centred approach to recruitment and selection. We looked at the staff records and found that the manager continues to ensure that a robust recruitment procedure is followed in practice to make sure people are suitable to work with vulnerable people before they start work. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 21 Each newly appointed staff member undertakes a recognised induction programme to make sure they are not left in situations they cannot handle. Thereafter they are enrolled on a National Vocational training course in care and we identified that over 50 of the staff team have achieved level 2 in this qualification which exceeds the minimum standards. The manager also ensures that trained nurses receive regular training to refresh their knowledge and skills showing they are valued and supported to provide up to date evidence based practice. External health care workers told us in our surveys that the manager and staff have the right skills and experience to support people with social and health care needs. The staff team tell us they feel knowledgeable and supported in their roles and have access to training that helps them undertake their role safely. People using the service feel there is enough staff on duty to meet their needs and we have not received any concerns about staffing levels over the last year. Record keeping, care practices, training and development have continuously improved and show that there are no identified shortfalls in staffing numbers at this time. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): 31-33-35-38 People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager continues to develop the service in the best interests of people who live there. EVIDENCE: Since taking up her role as registered manager in October 2008 she has worked consistently to improve the outcomes of people living at the home. The manager has demonstrated that she is knowledgeable and aware of her responsibilities; she has improved care planning, medication practices, and Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 23 delegated trained staff to take on responsibilities for different roles that has empowered them to improve care practices in the home. The staff we spoke to had great respect for the manager, found her to always listen and be available to them. They said that “she gets things done, the home is running much better and the décor is improving”. The manager has ensured that there are systems in place that regularly monitor the quality of the services provided to people and that staff are adhering to safe practices at all times in particular the medication practices which are now robustly monitored. There has been continuous improvement and actions taken to address any shortfalls identified through our inspections and those of the Local Authority monitoring officers and the Primary Care Team audit. The service does not hold money on behalf of people who live there. The service pays for any items the people need and then invoices them the last inspection saw the receipts and individual account sheets for the people who live at the service. The Manager has ensured that some ground floor rooms that are without automatic door closures are kept closed at all times and is completing risk assessments to ensure people are safe. She told us that following a fire inspection visit in May 2009 the provider has been issued with a notice of improvement by the fire officer to fit automatic door closure devices and a timescale for the completion of this work has not yet been agreed with the provider. Staff are trained in health and safety matters and records we saw showed they have received training in first aid, moving and handling and fire awareness Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 24 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 4 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X X X 3 STAFFING Standard No Score 27 4 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 23(4) Requirement You must consult with the Fire Authority on the timescale for fitting automatic door closures and prepare a risk assessment that describes the actions taken to control any risk to people in the home and take adequate precautions against the risk of fire. Timescale for action 09/09/09 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard OP8 OP8 OP9 Good Practice Recommendations Continue to develop the care plans to ensure they include best interest decisions in line with Mental Capacity Act legislation Include the type and size of hoist slings within the care plans of people that require the hoist. You should sign and witness all hand written medicine DS0000026443.V376713.R01.S.doc Version 5.2 Page 26 Hawthorne Care Home record sheets to reduce the risk of error. 4. 5. 6. OP15 OP26 OP38 You should total up the 24hour fluid intake record sheets to enable staff to use the information to determine if suitable hydration has been achieved. Continue to develop your infection control policy in line with the guidance provided from the Primary Care Team. Consult with the Environmental Health Officer on the number of staff that should be trained in Safe Food Hygiene practices. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 27 Care Quality Commission East Midlands Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Hawthorne Care Home DS0000026443.V376713.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!