Care Home: The Hawthorns

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What the care home does well The service user guide for The Hawthorns is a clear and detailed document, and people had received thorough assessments of their individual needs before they moved into the home. This means that people moving into the home and the staff have the information necessary to make a decision about whether the person`s needs can be met at the home. There is an established staff team at the home. Staff are keen for high standards to be maintained so the people living there receive good quality care. Day to day supervision of staff was good and staff receive regular formal supervision so they get good support from the manager to make sure they can provide good care for people living in the home. Regular staff meetings were also taking place so staff could have a say in how the home was being run to make sure the needs of residents were being met. The manager is competent and well qualified and he makes good use of the information gathered via the quality assurance process, showing that the views of the people who live in the home are important in planning future developments and improvements at the home. Plans of care and individual case notes for people who live in the home were thorough so staff know what they should do to meet people`s needs. Referralsto the appropriate health professionals take place when necessary to make sure that people living in the home stay as healthy as possible. The medication system is clear and well managed, with some residents looking after their own medication, so people who live in the home get their medicines as required. Meals were varied and reflected each person`s preference. They offered choice, when requested by the people who use the service, and variety so people living at the home were able to enjoy a varied diet to help keep them well and healthy. The home is clean and well maintained so people live in comfortable, homely surroundings. People who live in the home and their relatives know how to make a complaint about the home. Any concerns they have are dealt with quickly and effectively so people can be confident that their concerns will be listened to and acted upon. People living in the home told us, "I always receive the support and care I need", "we have a very caring group of staff" and "I usually know who to speak to if I am not happy". Other comments included, "The home is always fresh and clean" and "I usually like the meals". Staff said, "We do basic care of all the residents well. I am happy with the service given by this company", "we are always well staffed on a day to day basis" and "we provide a high standard of personal care and we can meet the needs of the individual." Other comments from staff included "The home has a good reputation and has more positive than negative comments", "we deliver a high standard of care" and "I feel proud of working in this home because of the standard of care and good reputation". What has improved since the last inspection? People who live in the home and their families or representatives are now more involved in completing their own care plans so they can have a say in how staff provide their care. Notices regarding activities and events at The Hawthorns are now also displayed upstairs as well as downstairs so that as many people as possible who live in the home can see what activities are available for them to take part in. What the care home could do better: Further consideration should be given to producing the service users` guide in different formats so all people who live in the home or may be interested in moving in can understand the information about the home more easily. CARE HOMES FOR OLDER PEOPLE The Hawthorns Hawthorn Street Wilmslow Cheshire SK9 5EJ Lead Inspector Maureen Brown Key Unannounced Inspection 15 September 2008 09:35 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 The Hawthorns DS0000006541.V367703.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. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service The Hawthorns Address Hawthorn Street Wilmslow Cheshire SK9 5EJ 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) 01625 527617 01625 539398 ken.kingsmill@clsgroup.org.uk www.clsgroup.org.uk CLS Care Services Limited Kenneth Kingsmill Care Home 39 Category(ies) of Dementia - over 65 years of age (1), Old age, registration, with number not falling within any other category (38) of places The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 This home is registered for a maximum of 39 service users to include: * up to 38 service users in the category of OP (old age not falling within any other category) * one named service user in the category of DE(E) (dementia over the age of 65 years) who may be accommodated within the total of 39 beds The registered provider, must at all times, employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 19 September 2006 2 Date of last inspection Brief Description of the Service: The Hawthorns is a purpose built care home for older people requiring personal care run by the CLS Group, a non-profit making organisation based in Cheshire and Wigan. The care home is in a residential area about ten minutes walk from the centre of Wilmslow. It is on two floors and there is a passenger lift to both levels. Five of the thirty-nine single rooms have an en suite toilet and washbasin. The rest of the rooms have washbasins in them and toilets nearby. There are four lounges, two dining rooms, a small sitting area in the entrance hallway, and a fully equipped hairdressing room. There are a variety of aids and adaptations around the building to allow people who live there to move about more independently. There is a garden with benches in an enclosed patio. There is off the road car-parking facilities to the front and side of the building. The current fees for the home are from £367.40 - £490.00 per week. Optional extras include hairdressing, chiropody and newspapers. The Hawthorns DS0000006541.V367703.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 stars. This means that the people who use this service experience good quality outcomes. We carried out an unannounced visit to this home on 15 September 2008; the visit lasted seven and a half hours. This visit was just one part of the inspection. Before the visit the home manager was asked to complete a questionnaire to provide up to date information about the home. We sent out questionnaires to people living in the home and staff to find out their views about it. Other information since the last key inspection was also reviewed. During our visit we looked at various records and the premises. We looked at care records of a number of people who live in the home, to see how their needs were being met. We spoke with a number of people who live at the home and staff and they gave their views about the service. What the service does well: The service user guide for The Hawthorns is a clear and detailed document, and people had received thorough assessments of their individual needs before they moved into the home. This means that people moving into the home and the staff have the information necessary to make a decision about whether the person’s needs can be met at the home. There is an established staff team at the home. Staff are keen for high standards to be maintained so the people living there receive good quality care. Day to day supervision of staff was good and staff receive regular formal supervision so they get good support from the manager to make sure they can provide good care for people living in the home. Regular staff meetings were also taking place so staff could have a say in how the home was being run to make sure the needs of residents were being met. The manager is competent and well qualified and he makes good use of the information gathered via the quality assurance process, showing that the views of the people who live in the home are important in planning future developments and improvements at the home. Plans of care and individual case notes for people who live in the home were thorough so staff know what they should do to meet people’s needs. Referrals The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 6 to the appropriate health professionals take place when necessary to make sure that people living in the home stay as healthy as possible. The medication system is clear and well managed, with some residents looking after their own medication, so people who live in the home get their medicines as required. Meals were varied and reflected each person’s preference. They offered choice, when requested by the people who use the service, and variety so people living at the home were able to enjoy a varied diet to help keep them well and healthy. The home is clean and well maintained so people live in comfortable, homely surroundings. People who live in the home and their relatives know how to make a complaint about the home. Any concerns they have are dealt with quickly and effectively so people can be confident that their concerns will be listened to and acted upon. People living in the home told us, “I always receive the support and care I need”, “we have a very caring group of staff” and “I usually know who to speak to if I am not happy”. Other comments included, “The home is always fresh and clean” and “I usually like the meals”. Staff said, “We do basic care of all the residents well. I am happy with the service given by this company”, “we are always well staffed on a day to day basis” and “we provide a high standard of personal care and we can meet the needs of the individual.” Other comments from staff included “The home has a good reputation and has more positive than negative comments”, “we deliver a high standard of care” and “I feel proud of working in this home because of the standard of care and good reputation”. What has improved since the last inspection? People who live in the home and their families or representatives are now more involved in completing their own care plans so they can have a say in how staff provide their care. Notices regarding activities and events at The Hawthorns are now also displayed upstairs as well as downstairs so that as many people as possible who live in the home can see what activities are available for them to take part in. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 7 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. The Hawthorns DS0000006541.V367703.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 The Hawthorns DS0000006541.V367703.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): 1&3 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People receive enough information about the home for them to make an informed decision about moving into the home and their needs are assessed before they move in so they know these can be met at the home. EVIDENCE: The statement of purpose and service user guide was produced in one bound folder, with people having a copy in their bedrooms. It was written in plain English, in large print with some photographs included. This had been reviewed in July 2008. A recommendation was made about looking at providing it in other formats to help all people who live in the home and others who are interested in moving in understand what services are available at the home. The manager told us that they were looking at producing an audio copy. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 10 Some people who live at the home confirmed that they were involved in the process of planning their own care so they were able to make sure that care would be provided in the way they prefer. When we spoke with staff, we could see that they were aware of the needs of the people living in the home, so they knew who needed what care and how it should be given. Each care file we looked at contained an initial assessment and support plan the identified the person’s needs. Information gathered at the assessment done before the person moved into the home included personal details, information about GP, social interests, communication needs and personal and healthcare needs. The manager also receives the local social services standard assessment document and other supporting documentation about the person. This is used, together with the assessment carried out by staff at the home, to make sure that people who move in can be well supported by the staff team. The manager confirmed that intermediate care is not provided at The Hawthorns. The Hawthorns DS0000006541.V367703.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 & 10 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The healthcare, personal care and social needs of people living at the home are met effectively by the staff team in a way that enables them to maintain their privacy and dignity. EVIDENCE: We looked at care plans of four people who live in the home, to check the care they receive. The plans contained all the information necessary to ensure that people’s needs are met. They were clearly written and covered areas such as healthcare needs, communication, eating and drinking, personal care, mobilising, work and play, sleeping and dying. Also included in the care file was a my life profile which details aspects of a person’s life and their achievements, as well as their likes and dislikes. It was a very useful document for the staff team to get to know each person and what they preferred. The daily records we saw were good and staff noted any changes to people, activities they had undertaken and the details of visitors were also recorded so staff and others could see that people were well and active. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 12 All files we looked at had reviews of the care plans to make sure that these were up to date and still effective. Many of the people living in the home were not able to confirm that they had been involved in planning or reviewing their own care. However they were able to confirm that staff helped them when they needed it, such as with personal care tasks. They told us, “The staff are always available when I need them”, “I am happy in the home” and “I always receive the care and support I need.” Where possible the resident or their families confirmed they were involved in their own care planning process so they could have a say in how their care was provided. Risk assessments were included in the care plans. These had been carried out for falls and moving and handling for all people living in the home. Mental health risk assessments had been carried out where needed. The risk assessments were done to make sure that people were safe in their daily activities and that any help they might need was identified. The medication system used at the home is a monitored dosage system. The medicines are stored in a trolley, which is kept locked when not in use. Any unused medicines are returned to the pharmacy each month to make sure stocks of unused medicines do not build up and lead to errors being made. Staff are trained in medication awareness; the staff files that we looked at showed medication training undertaken. This is to make sure that all staff who give out medicines know how to do it safely so that errors do not happen. A senior member of staff was seen helping people to take their medication during lunchtime. She was aware of how each person preferred to take their medicines and carried the task out safely so that everybody received their correct prescribed medicines. Controlled drugs are kept correctly in the home. Visits from healthcare professionals were recorded and it was seen that GPs, district nurses, optician, audiologist and the chiropodist visited people living in the home regularly to make sure they remain well. The Hawthorns DS0000006541.V367703.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 & 15 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. People who use the service were able to take part in a range of activities so they can stay active and staff help people so they could stay in touch with their friends and family. EVIDENCE: An activities co-ordinator is employed at the home. She has recently returned to work after a long-term absence and the manager now expects that activities will resume on a more regular basis. Whilst the activities coordinator was off the staff team had worked well to provide some activities, including the trolley shop, which sells cards, sweets, soft drinks and toiletries to the people who live in the home. Other activities that had taken place included bingo, tea dances, arts and crafts and having visiting entertainers. An activities coordinator from another home in the CLS group had helped out to make sure that some activities continued to be available for the people who live at the Hawthorns. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 14 A log of each activity is kept and showed trips to the shopping centre, pub lunches, local shows and canal trips have been undertaken. Religious services take place on alternate Tuesday afternoons in the lounge and all are welcome to attend these. The hairdresser visits the home each week. People who live at the home told us: “There are usually activities I can take part in”; “Could do with more activities at the weekends” and “There are sometimes activities I can take part in”. People who live at the home are offered choices in various ways, such as in the time they get up in the morning and retire to bed at night, by choosing the clothes they wear, by deciding whether or not to join in planned activities and by deciding how they wished to be addressed. This enables them to keep some control over what they do each day and to stay as independent as possible. We looked at samples of menus and these showed that there is a varied diet, mostly of popular, traditional dishes at the home. During our visit, we saw lunch being served. There was a choice of food and drinks available during the mealtime and the dining area was a pleasant area to eat in. After the meal people who live at the Hawthorns told us they had enjoyed the meal. They said “I always like the meals” and “I always like the meals and they cater for my specific dietary needs”. Drinks are available in between meals and supper at bedtime. The chef told us that he speaks to people living in the home each day to find out their choices for meals. If people do not like the choices on offer then he will try to provide something they would prefer. A vegetarian choice is always available each day. During our visit, we watched staff at the lunchtime chatting and working with the people who live in the home. The staff were attentive to people and helped them when they needed it. The general atmosphere within the home was warm and friendly. The chef told us that as he helped with serving the meal, he knew how much people liked to eat and that some preferred a smaller meal than others. We saw that the meals served varied in size according to what people preferred. The Hawthorns DS0000006541.V367703.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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home’s procedures for complaints and for safeguarding adults are effective so that the concerns of the people who live in the home are listened to and they are protected from abuse or harm. EVIDENCE: Staff files we looked at during our visit showed that they had done training on safeguarding adults. The manager confirmed this and showed that he was aware of the policy, procedures and guidance on safeguarding. There are also policies available at the home on use of physical restraint, physical intervention by staff, recognising and reporting abuse of a vulnerable adult and speaking out at work (whistle blowing). Since our last visit, no referrals have had to be made from the home under Safeguarding Adults procedures. The complaints procedure was satisfactory and contained details of how to contact us. We have not received any complaints about this home since our last inspection there. The home had received two complaints, which had been resolved to the complainant’s satisfaction and the customer satisfaction log had been completed. People who live at the home told us they would contact the manager if they had any problems. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 16 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 & 26 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The home is well maintained so people who live there live in clean, safe and comfortable surroundings. EVIDENCE: During our visit, we toured the building. We saw all the shared (communal) areas as well as a number of bedrooms. There is a variety of shared space available including two dining areas, various lounges and an activities lounge. The home was clean and odour free. People who live in the home had made their rooms more homely using ornaments, pictures and furniture they had brought with them when they moved in. The home was seen to be in a good state of repair and the décor was good. People who live at the home told us that they liked their bedrooms, saying “I like my room” and “The home is usually fresh and clean.” The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 17 The home was light, airy and was warm. We spoke with a group of people who live in the home and they told us the temperature in the home was warm enough for them. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 18 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 & 30 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The recruitment procedures are thorough and staff have done a range of training so people who live in the home are protected from poor practice. EVIDENCE: The staff rotas showed the numbers staff on duty over the week. The staffing levels appeared to be sufficient to meet people’s needs. People who live in the home confirmed there were enough staff around to help them and during our visit we saw that staff were attentive to people’s needs. People living in the home told us, “the staff are always available when I need them”, “we have very caring staff” and “the staff group are very caring”. Staff told us they thought there could be “more staff hours for daily activities”. They also suggested, “Increase the activity programme particularly at the weekends” and “Increase the hours of the activities co-ordinator.” We checked four staff files. These had all the necessary pre-employment checks in place, including identity checks, Criminal Record Bureau checks, references, health checks and application forms. These checks are carried out to make sure that staff are suitable to work with the people who live in the home. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 19 The training staff had done included fire safety, moving and handling, safeguarding adults, medication awareness, managing difficult behaviour, care planning and review, health and safety and skin breakdown. A five-year learning and development strategy was in place for 2004 - 2009 to make sure that all the staff have done the training they need to provide good care for the people living in the home. Good progress has been made with NVQ training. Twelve out of eighteen staff had NVQ level 2 or above in care. One person is undertaking this award currently and five staff are due to start NVQ level 2 shortly. This means that a good percentage of the staff have a nationally recognised qualification in care to help them provide good quality support for the people who live in the home. Regular staff meetings are held. The last one before our visit was in August 2008 and it was noted that staff discussed the people who use the service, staffing levels, supervision, training and reports of visits to the home done by other managers of the organisation to check how the home is running. The senior team for the home also meet regularly and their last meeting was also in August 2008. These regular meetings help to make sure that managers and staff know what is happening in the home, any changes needed and that things continue to be run in the best interests of the people who live in the home. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 20 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, 36 & 38 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The procedures within the home are thorough so the health, safety and welfare of the people who live there are protected, the staff are well supervised and there are processes in place to make sure the home is run in the best interests of the people who live there. EVIDENCE: The manager is a qualified nurse and has many years experience in providing care for people. He also has the Registered Managers Award, NVQ Level 4, is a moving and handling instructor and fire safety trainer so he can provide some of the necessary training for staff working in the home. He has worked for CLS for twelve years and has been the manager at the Hawthorns for four years so The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 21 he knows the home and can make sure that it is run well for the people who live there. There is an established quality assurance process for the home. Satisfaction surveys were sent to people who live at the home, their families and professionals involved in their care to complete in June 2008. A summary of the results has been put together and will be circulated once senior management have approved it. Other managers from CLS visit the home each month unannounced to check how it is running. The most recent visit before our inspection was on 19 August 2008 when no particular problems were raised. Other quality assurance processes include reviews of people who use the service to make sure their needs can still be met at the home and residents’ meetings. The most recent residents’ meeting before our visit was held on 20 June 2008 and issues discussed included staffing, outings and the service user questionnaire. This helps to make sure that the people who live at the home have a say in how it is run. The manager told us that some money is kept at the home on behalf of the people who live there. This is kept secure and appropriate records are kept to show that people’s money is safeguarded. Safe working practices were in place in the home. There were up to date safety checks on the home’s gas installation and electrical system. There were policies available in the home about safe working practices, including a range of risk assessments, dealing with hazardous substances, moving and handling, MRSA, health and safety, food safety and first aid. We also saw the fire safety equipment tests logbook. Up to date checks had been made on the extinguishers and fire safety system as required and regular fire safety awareness training had been provided for staff so they would know what to do to protect people if there was a fire. We saw the accident records and noted that a falls, accident and incident audit is carried out each month. Where a person has had a number of falls this generates a specific risk assessment, which must be carried out with that person. This makes sure that any risks to people are minimised so they are safe and can remain as independent as possible. These systems and checks mean that the home continues to be safe for the people who live and work there. Day to day supervision of staff was good and formal supervision is undertaken six times a year with records kept. Annual personal reviews (appraisals) are completed each year with records kept. This makes sure that staff have a chance to discuss their work with managers, so they can continue to provide good quality care for the people who live in the home. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 22 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 3 X 3 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 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 3 X 3 The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 23 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. 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 OP1 Good Practice Recommendations It is recommended that the service users’ guide is made available in different formats, such as audio visual formats, so people who live in the home or who may be interested in moving in can receive information about the home in a way that is easiest for them to understand. The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North West Region Unit 1, 3rd Floor Tustin Court Port Way Preston PR2 2YQ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries.northwest@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 The Hawthorns DS0000006541.V367703.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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