Hawthorne House

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

Processes to manage risks were not always effective. People’s care records did not always include information to ensure staff supported people consistently and safely. Some staff were not aware of changes to people’s risks. Medicine management required improvement. We could not be confident that people received medicines as prescribed. Managers understood local processes and procedures for ensuring continuity of care as people moved between services. Overall, records of people’s referrals and healthcare appointments were made at times people needed. Rotas demonstrated staffing levels were maintained to ensure people received their allocated support hours and there were staff with the necessary skills to support people.

This service scored 53 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received mixed feedback about a learning culture at the home. Some people were positive about raising concerns and action being taken. One person said, “They are on top of things’. However, 33% of people told us they had raised or given feedback and there were no changes meaning those people did not feel heard. Comments included, “I’ve told them but they don’t try and help, there’s not been any improvement” and “I ask them but things stay the same.”

The manager was committed to improving standards through learning and sharing best practices. The manager told us of the challenges to do this with a changing staff team. We found not all staff understood people’s risks, especially when people’s needs had changed. For example, specialist equipment people needed to manage skin integrity were not checked and when they were changed, this was without following guidance. The director explained a lot of work had been made to learn from previous experiences and this still needed to be improved upon. The manager acknowledged there was room for improvement and was confident the culture would mean staff took ownership to improve outcomes for people.

The Director showed us their processes across the provider group to learn from previous inspections, learn from new or revised guidelines and to learn from their own in-house quality assurance. Learning was shared with staff through clinical meetings and handovers. Where some improvements had been made, these promoted additional learning in the staff team. The manager and director had increased heads of meetings, overall communication and created a process to assess internal mock inspections against CQC's new assessment process. However, we found some of those processes had not become fully embedded so previous issues identified at the last inspection, such as safe risk management and safe medicines management still required improvements.

People felt cared for and if they needed any support from other health professionals, this was arranged. One person told us they were waiting for a hospital appointment which had taken some time, however, this was not the fault of Hawthorne House.

The manager was confident people received the right level of service. People were supported by other health professionals such as speech and language therapist, chiropody, mental health, psychiatrists and GP's. The manager explained some challenges they faced, especially accessing and arranging prompt mental health support. The manager was working closely with the commissioners and other health partners across Warwickshire to access support for people. Feedback from commissioners and a care pharmacy team acknowledged improvement since the home managers appointment mid November 2023, but recognised more work was required.

Feedback from Integrated Care Board (ICB) and care pharmacy team acknowledged improvement since the home managers appointment during November 2023. The ICB had visited the care home numerous times to support the provider with improvements. Feedback from the ICB confirmed areas for improvement remained and they would continue to support and monitor progress.

Staff followed processes to ensure people who were admitted and discharged, had the relevant information required to support and promote good outcomes. Some people at Hawthorne House were on a ‘discharge to assess’. This is a process that allows people who are clinically stable to leave acute care, even though they may still need support after being discharged to their own home or another, permanent place of residence. There were processes to ensure staff had the right and relevant information to support the person. Care plans, risk assessment tools were used to meet people’s needs. There was a pre-admission assessment and checklist for admissions and information from the hospital for people being discharged from hospital to the service.

Overall, people told us they felt safe and comfortable with the staff who supported them. Comments included, “I feel safe, I am well looked after,” “The staff look after you and make sure that you come to no harm.” A relative told us, "The staff look after mum excellently; her wellbeing is so much better.” However, another person told us, "Sometimes I feel safe and sometimes I do not. I don’t know why.” People said they felt safe at the home and in the company of staff. Relatives felt confident their family member was safe and they had no concerns about their safety.

Staff were confident to speak to senior staff about any concerns. One clinical staff member explained how they observed staff to identify any practice that could expose people to risk. They told us, "I also have a look at what the staff do and if the person has a bruise, it could indicate staff may not be handling residents correctly. If there is anything, I will let the staff know. I would definitely report it directly to my manager and do an incident report as well.” The manager took action in response to concerns and knew how to keep people safe from the risks of abuse.

The atmosphere on the units, within the home, were calm during the day of our on-site assessment. We saw one person became upset, and a staff member promptly gave reassurance. People were relaxed around staff and people did not raise any issues to us. People were smiling and talking with staff. Staff knew people and spoke to them by name. We observed staff talking to people appropriately, however they did not always seek consent before supporting people. For example, we saw staff on more than one occasion go into people’s rooms without knocking the door, waiting, or asking if it was okay to enter. We mentioned this to the manager to ensure staff recognised people’s privacy.

The manager completed and referred allegations of concern to local safeguarding teams and to us (CQC). The manager understood what and how to report any incidents of poor practice. The manager told us they had worked closely with the local safeguarding team to review any outstanding referrals and to ensure actions were taken to make sure people remained safe. Safeguarding referrals were reviewed as part of the provider's quality assurance process to keep people safe and protected from risks of abuse.

Where people had staff to support them with equipment or additional staff, people said this was provided and they felt safe. However, 8 people told us they did not have call bells and 1 person said if they needed assistance, they had to “shout for help.” Whether this person received the help they required depended on whether staff were in the vicinity to hear this person's shouts.

We received mixed feedback from staff about risk management. One nurse told they did not consistently work on 1 unit within the home but across all 7 units. They told us this meant they did not always know people as well as they would like and this included risk management for people. Another nurse told us people living on 1 unit might, on occasions, be moved by management to live on another unit and they (the nurse) were not always made aware of when moves were to take place, which meant they were not familiar with the person or their risk management plans. Another care staff member told us, "I don't know people well as we get moved about all the time." Staff told us communication during handovers between shifts ensured any changes in people's risks were shared with them. Comments included: “Every morning, we come at 7.15am and the night staff leave at 7.30am. In that 15 mins we get a proper handover of what has happened" and, "We always have a handover meeting in the morning, and they will give you a handover of the situation of the residents and we check up on our residents before we start our day." However, our findings did not consistently support all information was effectively communicated between staff. Staff told us they worked as a team to ensure observations of people were maintained to keep them safe.

We observed some practices that posed potential risks to people, such as slips and trips. One person was anxious and asked us into their bedroom to show us what they called a ‘flood’ on their ensuite floor. A nurse told us staff had supported the person to shower earlier in the morning, but a lot of water had not drained away and continued to not drain leaving most of the ensuite floor covered in water. No immediate action was taken to address this risk, after we had pointed out the water to a staff member. We observed examples of where care staff should have communicated information to nurses so appropriate action could be taken. For example, one person had a full container of 'over the counter' purchased vitamin supplements in their bedroom. When we asked the nurse if these were safe to be left in the person's bedroom, they told us the care staff should have alerted them about these because they should not have been left on the person's bedside cupboard. However, no immediate action was taken to remove them.

There were processes to manage risks to people, yet we found these were not always effective. We found specialist mattresses were not set correctly and when we pointed this out to a nurse, they changed the setting without investigating or finding out what was the correct setting should be for each person. Risks related to medicines were not always managed. We found topical creams, medicines stocks and covert medicines were not always checked, and staff knowledge was not always consistent with pharmacy guidance. The provider had identified 134 ‘as and when’ medicine protocols needed to be completed for medicines prescribed and being given to people by staff. Some risks related to infection prevention and control were not identified and for some fire safety checks, it was not clear if they were completed or not. The provider had identified people’s care records were not always accurate. We found people’s risk management records were not reviewed or in some cases, did not contain the relevant information to help staff provide consistent care. We found no evidence people had been harmed however, the provider failed to robustly assess all necessary risks relating to the health safety and welfare of people. This placed people at risk of harm. This was a continuing breach of regulation 12 (Safe Care and Treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

During our visit, the majority of people were positive about their environment and equipment. Comments included, "They hoist me from the bed to chair, I feel safe when they do this.” And, “I have not noticed any danger around the home for me to be concerned.” One relative told us, "I have no concerns with the home, its clean every day, [Staff Name] on cleaning is brilliant and the laundry is done regularly." However, a person told us, "They sometimes do maintenance at night, or painting. I can smell the fumes from the paint." Another person told us, “The place is too warm sometimes.” We found at least 8 people did not have alarm call bells, which was confirmed by people spoken with. One person said, “I can’t reach my buzzer; I have to shout for attention” and another person said, “They (staff) pull out the call bell so I can’t use it.” We fed this back to the manager to review people’s needs and use of systems to be able to call for help when required.

Some staff were not aware if equipment used to support people remained fit and safe for use. We found 3 examples of people using air flow mattresses to help maintain their skin integrity were set incorrectly. Staff told us it was not their responsibility to check those air flow mattresses and that it was the care home maintenance staff who should undertake these checks. In one example, an air flow mattress pump was flashing red. Staff had not noticed this and could not tell us how long it was flashing. It was unclear whether this meant there was a fault with the pump or whether this was indicating a fault in the inflation of the air flow mattress. Staff told us they raised issues on their electronic reporting system but were not always aware if actions had been taken. One care staff member told us they had reported broken mirrors in people's bedroom ensuites but no timely action had been taken. A nurse told us they had reported a lack of keys being available for people's bedroom ensuite lockable cabinets, but no action had yet been taken. We were told conflicting information whether fire door checks were undertaken at required intervals. During our visit, we found 1 fire door propped open and another closed too quickly. The estates manager told us they had not completed regular checks of fire doors. They told us they were last checked in September 2023 and were due again September 2024 having undergone some refurbishment. However, we were given April and May 2024 fire checks post site visit.

Some storage of equipment and supplies posed potential risks of injury to people. For example, we saw a stand aid hoist stored in a person’s bedroom ensuite, but this person was mobile and did not require this equipment. Another hoist had been left on charge in a person’s bedroom with wires trailing on the floor. A further person had three large boxes of continence supplies stacked on their bedroom floor. A staff member told us, “The pad deliveries used to be stored somewhere else, but now we just put them in people’s bedrooms.”

Processes were not effective, known or robust to ensure maintenance and a safe environment were maintained. Our evidence included conversations with staff which showed staff were not clear what and how to report. There was no known process to inform staff what had been made good. We asked the manager/estate manager for fire safety checks and we were given limited conflicting information of completed checks. On site, the estate manager confirmed the last fire door checks were September 2023. H&S monitoring such as water quality, health and safety were completed, however, our observations recorded broken mirrors and 2 fire doors that had not been made good. Staff were not clear what the process was to report/rectify issues because action was not always taken.

We received mixed feedback from people about staffing. Most people told us staff were available to help them and meet their needs, however, some people also told us staff were too busy. One person said, “I have noticed lots more staff today, they won’t be here when you go. It will be back to normal.” People told us they sometimes felt lonely or isolated and wanted staff to spend a bit of extra time with them. Relatives shared similar concerns to us and said it had recently improved because reliance on agency staff had reduced. People and relatives were complimentary about the staff who supported them.

We received mixed feedback from staff as to whether there were enough staff to provide safe and effective care. Most staff told us staffing levels were good. Comments included: "I have no issues with the staffing levels” and "Staffing levels are good here." However, some staff shared concerns about staff numbers. One staff member commented, “They need more staff to deliver quality care. You are putting more pressure on the staff and less care on the residents." We discussed staffing arrangements with the manager. The manager described robust processes to assess safe staffing levels and if needed, staffing was increased if there was a change in people’s needs. Where people had 1:1 staff support, this was in place. Staff received regular training and new staff had an induction which included shadowing more experienced staff. Staff told us the training they received enabled them to provide safe and effective care.

Staff were visible on each unit and available to support people when they needed it. People who required an increased level of support and supervision to keep them safe, had an allocated member of staff with them. Staff did not appear rushed and communicated with each other to ensure observations of people were maintained to ensure their safety. Whilst we saw people received support when needed, our observations showed the help people received was more task orientated than person centered.

Managers attended a weekly ‘bed management meeting’ to discuss people’s needs and any accidents and incidents. This helped to identify any deterioration in health which may indicate a person required a higher level of supervision and support. Where a need was identified, staffing levels were increased to mitigate emerging risks. The provider checked the profiles and qualifications for agency staff to ensure they had the right skills and knowledge to support the specific needs of people living at Hawthorne House. The provider completed the required checks to ensure staff were of suitable character. Safe recruitment checks included obtaining written references from previous employers and checks with the Disclosure and Barring Service (DBS). DBS checks provide information including details about convictions and cautions held on the Police National Computer. The information helps employers make safer recruitment decisions.

People had no concerns about the cleanliness of the home or their own bedroom.

A member of domestic staff told us they had received training in infection control practices and the correct use of personal protective equipment (PPE). They told us they were informed when somebody had an infection in the care home so they could ensure increased use of PPE and implement extra precautions to minimise the risks of infection spreading. Staff shared their concerns with us over a lack of clean bed linen and towels. One staff member told us, “The washing machine has been broken for a few weeks, it’s not the first time.” The manager used one of the provider's other homes to support them with ensuring laundry was managed without too much impact on people. Some staff told us at times, there was not enough clean items.

Communal areas of the home were regularly cleaned by housekeeping staff. However, some practices we saw posed risks of cross infection and ill health to people. We found a commode pot had been placed in a bedroom ensuite sink with the person’s toothbrush against the rim of the commode pot. Another person’s toothbrush had been placed in their toilet roll. Some people’s toiletries were stored on the back of toilet cisterns because there was no shelf in their bedroom ensuite to store their toiletries. Some mirrors in bedroom ensuites were damaged which meant effective cleaning could not take place. A bedside table was stained and dirty and had been placed in the person's bedroom ensuite. A nurse confirmed to us this person used the table for food and drinks. When we pointed out our observations to a nurse, they told us, “These things should not happen.” Following our visit, the manager agreed to implement a regular environment check to ensure cross infection risks were minimised.

There were processes to monitor and ensure infection control risks were managed safely. Some of the processes included a daily walkaround, but we found numerous occasions where they were not completed. Where we observed poor infection control measures, staff did not take ownership in taking immediate action to address issues. We also found staff were not always clear if issues were reported. Some quality assurance checks did look at the environment which meant issues were not always identified as requiring improvements.

Overall, people told us they had their prescribed medicines available to them and they were supported by trained staff to take them. Comments included, “ [Person's Name] has their medication regularly.” I get medication on time, they don’t forget.” One relative told us their family member had their medicines disguised in food and drink to help them ensure it was taken. No one raised any concerns to us in how their medicines were administered.

Through staff conversations we were not confident staff followed safe medicines practice. Some people were prescribed medicines ‘when required’ and had protocols in place to guide staff on when the medicine should be given. However, others did not and not everyone’s individual medicine support needs were documented which meant staff did not consistently have the information they needed. One person was prescribed a medicine for when they became anxious. A nurse confirmed to us there was no protocol in place to give ‘as and when’. Where people had ‘topical’ medicines such as creams, a body map was available to tell staff where on the skin the cream should be applied. However, not all care staff knew where to find this. Topical creams were not always stored securely. Creams did not always have a date of opening. In 1 example, 1 person had a pot of cream in their bedroom with another person’s name on it. A staff member told us, “That person moved out about four weeks ago.” These issues posed potential risks of people not consistently receiving creams in a safe way. When people had their medicines covertly; hidden in their food or drink, information for staff to do this in a safe way was not always in place. For example, a nurse told us they had crushed medicines for 1 person to covertly administer, we saw this nurse give a yogurt to the person containing the disguised medicines. The nurse told us this person had no covert protocol in place. Another person’s covert protocol incorrectly listed a topical skin cream to be given covertly in food or drink. This meant that there was a risk that some medicines might not be given in a consistent and safe way. Some people were prescribed transdermal (skin) patch medicines. A nurse told us there was no system in place to check people’s transdermal patches remained in place so it made it difficult for staff to reapply a patch to a new site on the person's body.

There were processes to train staff, and assess their competencies, in the safe handling of medicines. This helped ensure people received their medicines safely. Medicine safety and security processes included monthly checks. Where medication errors had occurred, these were investigated, and actions taken to minimise the risks of reoccurrence. However, we found processes to manage medicines required improvement. Some audits had identified areas for improvement, checks were not always effective in ensuring improvements were made and embedded in practice. For example, in the resus bag the same equipment had been listed as “not available” for 7 weeks. No action was taken to rectify this. Stock checks were ineffective which posed potential risks of insufficient stock of medicines. The manager had notified us of a recent (May 2024) incident where medication could not be administered to a person because there was no actual stock available in the care home, despite electronic records having shown stock available. For numerous medicines the EMAR recorded stock as ‘Not applicable’ but actual stock was available. Three nurses spoken with were unable to say why this was. Where a stock amount was listed on a person’s EMAR, this was not always the same as the actual stock. For example, one person’s EMAR listed zero stock, but the person had 140 tablets in stock. We identified other discrepancies in stock recording which included one medicine with specific legal requirements for safe storage. This meant the provider’s medicines management system needed improvement to ensure the safe management of medicines. Following our visit, the manager sent us copies of ‘as and when’ protocols introduced, however these remained a concern to us because they were not clear. We found different areas of medicines management and staff knowledge had potential to put people at risk. This was a continued breach of regulation 12 (Safe care and treatment) of the Health and Social Care Act 2014.