Care Home: Hawthorns Lodge Limited

What the care home does well People, who used the care service, were seen freely moving around the home. People could choose to sit in the lounges or stay in their bedrooms, as they wished. There are regular visits by Dentists, a Chiropodist and an Optician. One person was very happy the Dentist called at the home, s/he told us, "I am now getting my teeth sorted out, at last". In a survey a person wrote, "Mum/Dad`s needs are constantly changing and the staff do their up most to make sure Mum/Dad is happy, safe and comfortable ". A relative told us, "The home is small and more cosy than others I looked at. My mother/father is really happy here". Other comments from people were: "All staff are pleasant and friendly. My Mother/Father is very happy and well looked after at Hawthorns Lodge" "The home has caring and friendly staff. Staff always keep me informed of my parent`s health condition" "They care" "I am more than happy with the care my Mother/Father is receiving". The home provided regular activities for people who used the service. There was a good relationship between people who worked and lived at the home. In a survey a person wrote, "Hawthorn Lodge has a homely feel to it. That is why I chose it". Management and staff obviously enjoyed looking after people who lived at the home. Staff complete thorough induction training, basic and further training was provided for staff. All but one member of staff had successfully gained National Vocational Qualifications at Level 2 or Level 3 and the remaining member of staff was undertaking that training. Many staff had also completed specialist training, for caring for people with dementia. What has improved since the last inspection? This is not applicable as this is the first inspection. What the care home could do better: Risk Assessments should be reviewed with Care Plans. The manager must complete the application process, to become the registered manager of the home. CARE HOMES FOR OLDER PEOPLE Hawthorns Lodge Limited High Street Loftus Saltburn-by-Sea TS13 4HW Lead Inspector Brenda Grant Key Unannounced Inspection 10:00 10th April & 9th May 2008 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 Lodge Limited DS0000070310.V361713.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. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hawthorns Lodge Limited Address High Street Loftus Saltburn-by-Sea TS13 4HW 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) 01287 641508 P/F 01287 641508 The Hawthorns Lodge Limited Position vacant Care Home 20 Category(ies) of Dementia (20) registration, with number of places Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home only - code PC To service users of the following gender: Either Whose primary care needs on admission to the Home are within the following category: 2. Dementia - Code DE, maximum number of places 20 The maximum number of service users who can be accommodated is: 20 Date of last inspection: This is a new service. Brief Description of the Service: Hawthorns Lodge Ltd is a purpose-built home that opened in 2007. There are 20 beds available to people suffering from dementia. The home is in the centre of Loftus and close to local shops, churches and a doctor’s surgery. Hawthorns Lodge Ltd is a single storey building. Within the home there are choices of communal lounges and dining rooms. There are also communal bathrooms, showers and toilets that have suitable equipment to assist people with physical disabilities. All bedrooms are for single occupancy; having en-suite facilities consisting of a toilet and wash hand basin. People who use the care service are able to personalise their rooms, according to preference and taste. At the side of the home there is an enclosed courtyard, enabling those who live at the home to access a secure outdoor space. The courtyard has solar lights and lighting in the paving. There is also a water fountain, a raised garden and seating, for people to sit outside when the weather is warm. At the other side of the house there is a walled water feature with a fish-pond. People who use the care service enjoy watching the fish and feeding them. At the time of the inspection the fees ranged from £463.94 to £488.13. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was an unannounced inspection. We assessed the information from: the Annual Quality Assurance Assessment that had been completed by the manager, information we already had about the home and we carried out two visits to the home. The visits took place over two days, eleven hours and thirty five minutes in total. We received surveys completed by: four staff, seven relatives and/or carers and a health care professional. Discussion and observation took place with six people who used the care service, two relatives, two staff, the provider and the manager. We looked around the home as well as examining a number of records which included those for: staff and people who use the care service, health and safety and maintenance checks, complaints, accidents and medication documentation. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. What the service does well: People, who used the care service, were seen freely moving around the home. People could choose to sit in the lounges or stay in their bedrooms, as they wished. There are regular visits by Dentists, a Chiropodist and an Optician. One person was very happy the Dentist called at the home, s/he told us, “I am now getting my teeth sorted out, at last”. In a survey a person wrote, “Mum/Dad’s needs are constantly changing and the staff do their up most to make sure Mum/Dad is happy, safe and comfortable ”. A relative told us, “The home is small and more cosy than others I looked at. My mother/father is really happy here”. Other comments from people were: “All staff are pleasant and friendly. My Mother/Father is very happy and well looked after at Hawthorns Lodge” “The home has caring and friendly staff. Staff always keep me informed of my parent’s health condition” “They care” “I am more than happy with the care my Mother/Father is receiving”. The home provided regular activities for people who used the service. There was a good relationship between people who worked and lived at the home. In a survey a person wrote, “Hawthorn Lodge has a homely feel to it. That is why I chose it”. Management and staff obviously enjoyed looking after people who lived at the home. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 6 Staff complete thorough induction training, basic and further training was provided for staff. All but one member of staff had successfully gained National Vocational Qualifications at Level 2 or Level 3 and the remaining member of staff was undertaking that training. Many staff had also completed specialist training, for caring for people with dementia. What has improved since the last inspection? 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. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 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 Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards: 3 & 6 The care needs of individuals are assessed before moving to the home and people are assured those needs are met. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: A sample of five files, of people who use the care service, was examined. They contained assessments carried out by a care manager. Assessment information included general information as well as the person’s health, social and personal care needs. Additionally, when the opportunity arose, the home’s manager visited people and completed the home’s own assessment before people were admitted to the home. All of the assessment information was used to start a Care Plan. The manager told us, when people were admitted to the home they were allocated a Key Worker who was the person’s named carer. A relative told us, before admission s/he and his/her Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 9 mother/father was involved with the assessment process and s/he had the opportunity to look around the home. The manager told us, the home sometimes had emergency admissions. The home had policies and procedures for such admissions. The manager told us, care managers verbally informed the home of the person’s care needs. Assessment documentation was either brought with the person or delivered to the home soon after the emergency admission. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 10 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): Standards: 7, 8, 9 & 10 The health, personal and social care needs, of people who used the service, are met and recorded in Care Plans. People are protected by the home’s policies and procedures for dealing with medicines. People are treated with respect and their right to privacy is upheld. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: A sample of five Care Plans was examined. The home had developed a Care Plan for each person who used the service. The manager informed us, the home was implementing new Care Plans but not all had been completed. The new Care Plans had information about the person’s care needs and details of how those needs would be met. All of the Care Plans did not have signatures of the person, or their relative, showing they were involved with Care Plans. The manager told us, the home had started to request relatives to sign the plans. A relative we spoke with told us, “I was fully involved with my Mother/Father’s Care Plan. The manager discussed, in length, how care was to be delivered. I Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 11 am very satisfied with how the staff are looking after my Mother/Father”. The Care Plan information covered all aspects of caring and daily living. People were assessed for areas of risk. The home was developing new Risk Assessments but they had not all been completed. The new Risk Assessments detailed how risks would be managed; to reduce those risks to an acceptable level. The plans we looked at showed they had been regularly reviewed and updated. Risk Assessments had not always been dated or reviewed at the same time as the Care Plans. The manager told us, when all new Care Plans and Risk Assessments were completed, they would be reviewed and updated together. The files included healthcare matters, including healthcare visits and appointments. The records had details of the outcome of health care visits and if treatment was to be continued. A relative we spoke with told us, “Staff make sure people’s health needs are met and we are informed when a doctor or nurse is called to the home”. On the day of the first ‘site’ visit a Dentist visited the home to see two patients. The manager told us, the Dentist called regularly and there were also visits from a chiropodist and an optician. The manager told us, the home ensured referrals were made when specialist equipment and/or specialist healthcare treatment was needed. The home had suitable equipment, for staff to use when they assisted people with bathing and showering. The home took satisfactory action for managing people’s medicines. The home’s senior care staff usually administered medicines. Staff files confirmed staff had completed training for handling and administering medication. The medicine storage was found to be satisfactory. We looked at the Medication Administration Records. During our first visit to the home there were a few gaps in the records, where staff had not signed to confirm medicines had been administered. Our second visit confirmed, procedures had been put in place to make sure all medicine records were properly completed. Staff were observed being respectful to residents and knocking on bedroom doors before entering the room. People could stay in their own rooms or go to communal rooms as they wished. A relative told us, “The home made sure staff were sensitive with carrying out personal care and making sure resident’s dignity was maintained”. A person told us, “Staff are really good and they are very caring”. We noticed there was a good relationship between staff and people who lived at the home. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 12 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): Standards: 12, 13, 14 & 15 People have a lifestyle that suits them and they live as they wish. Individuals have choice and control over their lives and people maintain their contacts with families and friends. The home provides a varied and balanced diet for people who use the care service. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: Staff told us there were always activities taking place at the home. A relative told us, “They offer resident’s choices of things they want to do”. During our first ‘site visit’ there was no record of the activities that had taken place during the last two months. At our second visit we saw that activities were being recorded. People who used the care service had the opportunity to join in with activities that were organised by the staff. The manager told us, the staff tried to find out about people’s interests. She said, “We bought a bird table for a resident who wanted one”. The bird table was installed during our first ‘site’ visit. The manager also told us, there was a person who was interested in painting and drawing. The home arranged for a painter to go to the home, to give the person advice and encouragement with painting pictures. The home Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 13 had developed a link with a local school, for students who had physical disabilities. The home was to have a dog, with its owner, visit the home and people could enjoy watching, patting or taking the dog for a walk, accompanied by a member of staff. The home had tried to provide for people’s religious needs, by arranging representatives from religious sects to visit the home, but people had not wanted to be involved with them. The manager told us, the home would arrange for people to attend their own churches if that was what they wanted. The manager and staff told us that relatives and visitors were welcome to come to the home at any time. A relative told us, “Staff always make us feel welcome”. The manager told us, there were no visiting restrictions but it was preferable that people didn’t visit the home at meal times, to cause a distraction for people when they were having their meals We saw that people lived their lives as they wished. They were able to bring some of their personal possessions, to keep in their bedrooms. Staff told us, people could get up and go to bed whenever they wished. On the day of our first ‘site’ visit, one person had got up mid morning and had a late breakfast. The manager informed us, relatives usually looked after people’s financial affairs. A relative told us, s/he gave the home some money each month, so that they could pay for hairdressing and with buying toiletries and other small items. The home’s menus were examined, showing there was a variety of food offered to people and there was a choice for each meal. On the second ‘site’ visit people had fish for lunch. There were choices of: battered fish, fish fingers, fish cakes and one person had scampi. At our first ‘site’ visit, the menus that were displayed in the dining rooms were not the meals that were served at the home. On our second visit, the menus were correct. The lunch was well presented and the dining areas were very pleasant. The food stored at the home was of there being fresh fruit and vegetables and a good variety other dried, tinned and frozen foods. The cook kept a record of the food that had been served at the home and there were completed records for: the cleaning rota, fridge, freezer and food temperatures. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 14 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): Standards: 16 & 18 People are confident their complaints will be listened to, taken seriously and acted upon. Individuals are protected from abuse by the home’s policies and procedures. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: The home had a Complaints Procedure. It informed people, who they could make a complaint to and when they would expect to receive a response. There had been one complaint and it had been properly investigated and recorded. A relative we spoke with informed us, s/he did not have anything to complain about and s/he was very satisfied with the service. The home had cards and letters that complimented the management and staff for the service they provided. Complimentary comments included, “I would like to let you know how much I appreciate your dedication, patience and understanding towards residents and visitors at Hawthorns Lodge” and “You have set yourselves a very high standard, long may it continue”. The home had a copy of the Redcar & Cleveland Inter-Agency Policies, Procedures and Practice Guidance, ‘No Secrets’, for safeguarding adults. Staff records confirmed staff had completed induction training that included an awareness of adult abuse. All staff will be undertaking formal training, for safeguarding vulnerable adults. Staff said, they knew of the procedures to follow if there was an allegation of abuse on an individual. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 15 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): Standards: 19 & 26 People who use the service live in an environment that is safe and wellmaintained. The home is clean, pleasant and hygienic and free from offensive odours. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: Hawthorns Lodge Ltd was a newly built home. All furnishings and fittings were of a high standard and provided a homely, warm and comfortable environment. All bedrooms have en-suite facilities, with wash hand basins and toilets. Bedrooms also had telephones and there were small notice-boards, for staff and people or their relatives to communicate with each other. There was an attractive enclosed garden. It had a water fountain, lighting and seating. The manager told us, people had already been outside and enjoyed the garden Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 16 during the warmer weather. There was also a small raised garden where people could be involved with putting plants in the garden. There was another area that had a walled water feature and a fish-pond, people enjoyed feeding the fish. All parts of the building and garden were accessible to wheelchair users and people with physical disabilities. The home was well maintained and there was a record of all routine maintenance that had been reported and completed. Before the home opened it had been confirmed, the requirements of the Environmental Health Department had been met and all fire safety measures were in place. The home was clean, pleasant, hygienic and free from offensive odours. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 17 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): Standards: 27, 28, 29 & 30 The numbers and skill mix of staff are satisfactory. Staff are trained and competent to care for the people at the home. People are protected by the home’s recruitment procedures. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: On the days of the inspection ‘site’ visits there was sufficient care staff to meet the needs of the people who lived at the home. There was also laundry, domestic and kitchen staff. A relative of a person who used the service told us, “Staff are lovely and nothing is too much trouble for them”. Staff appeared to work well as a team. Senior care staff were allocated specific responsibilities and supported the manager. One senior had the responsibility for ordering medication and another was involved with planning staffing rotas. A sample of training records was examined. It was commendable that the numbers of care staff who had successfully completed the National Vocational Qualification at Level 2 or 3 was 93 , fourteen of a total of fifteen staff. The remaining member of staff had commenced that training. All of the care staff were females and the males who worked at the home were, a cook and the person who carried out regular maintenance checks. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 18 We looked at staff files. They contained completed application forms, interview details, references and checks with the Criminal Records Bureau. This confirmed the home had followed its recruitment and selection process. The manager told us, “Since the home opened, training has been a high priority and we will continue to make sure staff are trained to a high standard”. Staff had completed induction and basic training and extra specialist training in caring for people who have dementia. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 19 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): Standards: 31, 33, 35 & 38 The home is managed and run in the best interests of the people using the service. People’s personal money is safeguarded by the home’s procedures. The health, safety and welfare of staff and people who live at the home is promoted and protected. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including two visits to the service. EVIDENCE: The manager had six years experience of running a care home for older people. She had successfully completed the Registered Manager’s Award at Level 4 and National Vocational Qualification Level 4, in care. The manager was applying, to the Commission for Social Care Inspection, to become the Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 20 registered manager of the home. Staff told us, the manager gave support when it was needed. Quality Assurance, for the home, was by means of an independent company carrying out an audit of the service. People who used the service and/or their relatives were asked to give their views about the service. The independent company feedback the results of the audit to the manager but she had not written a report on the findings of the audit. The provider regularly visited the home, spoke with staff and people who used the service and produced a monthly report on the findings of his visits. The home had some good management monitoring systems in place. A manager, from another home, carried out regular audits of the service. The home had staff meetings that had taken place every two months. The meetings were an opportunity for staff to put forward their views about the service and discuss how the home was run. The manager regularly had meetings with relatives of people who lived at the home but those meetings had not been recorded. A sample of financial records, of monies held on behalf of people who used the service, were examined and found to be correct. A sample of health and safety records was examined and found to be in order. The manager kept an up to date record of all maintenance and checks that were required throughout the year. Checks for; electrical appliances, fire equipment and general Risk Assessments and those for the Control Of Substances Hazardous to Health were up to date. The home kept records of all accidents and there was a record for checks of the hot water outlet temperatures. Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 21 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 2 8 3 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 4 X X X X X X 4 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 X X 3 Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 22 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 OP7 Regulation 13 Requirement Risk Assessments, for people who use the care service, must be completed and reviewed and, when necessary, updated with Care Plans. This is so that all information about people is kept up to date. The manager must complete the application process, to become the registered manager of the home. Timescale for action 30/06/08 2. OP31 10 31/07/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 23 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 Hawthorns Lodge Limited DS0000070310.V361713.R01.S.doc Version 5.2 Page 24 - 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. 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