CQC report explained · a residential care home
What the CQC found at Hawthorn House
Rated Good: inspectors found the home performing well and meeting their expectations.
- Safe?
- Good
- People were protected from abuse and avoidable harm. Medicines, staffing, recruitment, infection control and incident responses were found to be safe, although some risk records lacked detail and fire-door work had taken too long.
- Effective?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Caring?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Responsive?
- Good
- This question was not inspected during this focused visit. The previous rating was used in calculating the overall rating.
- Well-led?
- Good
- The home had positive leadership, open working relationships and systems for reporting incidents and learning from them. Some monitoring systems still needed further development.
What inspectors found, June 2023
Rated Good; inspectors found safe, kind support and strong leadership, but some fire-door work and records needed improvement.
This was an unannounced focused inspection on 24 May 2023. Inspectors checked whether the home had improved after an earlier breach. They spoke with people, relatives and staff, observed care, checked the home and reviewed records, medicines, recruitment and management systems.
The home was rated Good overall. Safe and Well-led were both rated Good. People were supported to make choices, take part in activities and keep relationships. Staff were described as knowledgeable, caring and available in sufficient numbers.
Inspectors found some records did not contain enough detail. Fire-door safety issues had not been dealt with as quickly as they should have been. The provider had improved since the previous inspection and was no longer in breach of regulation 18.
Choice and independence
People were supported to make choices, use the local community, continue hobbies and take part in education and activities.
“People were supported to live their lives in the way they wanted through accessing education, the local community and pursuing their hobbies and interests with support from dedicated staff.” from the report
Safe medicines
Medicines were given as prescribed, stored properly and reviewed regularly with relevant professionals.
“People's medicines were administered safely and as prescribed.” from the report
Staffing and training
There were enough staff to meet people's needs. Recruitment checks, induction, training and competency assessments were in place.
“There were sufficient numbers of staff to keep people safe and meet their needs.” from the report
Positive culture
Inspectors found respectful relationships between people and staff. Staff also valued the support they received from managers.
“People and staff had formed trusting, respectful relationships as there was a positive culture at the service which benefitted people.” from the report
Fire-door work
needs fixingSome fire-door safety issues were still being addressed, and inspectors said they should have been resolved more quickly.
“However, we found shortfalls in fire door safety could have been resolved quicker.” from the report
Incomplete risk records
needs fixingSome records about risks to people's safety and wellbeing did not contain enough detail. The manager began addressing this during the inspection.
“However, we found some records lacked detail.” from the report
Monitoring systems
needs fixingSome quality checks needed more development so they could identify gaps in risk assessments and mental-capacity records.
“However, we found some needed further development to ensure they remained effective in identifying shortfalls with risk assessment and mental capacity records.” from the report
- 01Have all the fire-door safety issues now been completed, and when were they signed off?
- 02How do you make sure risk assessments and daily records contain enough detail?
- 03What changes have been made to monitoring mental-capacity records?
- 04How do you check that learning from incidents and near misses leads to changes in practice?
- 05Which ratings were carried forward from the previous inspection for Effective, Caring and Responsive?
This was an unannounced focused inspection of Safe and Well-led, including infection control; the other ratings were carried forward from the previous inspection. This explanation was written from the published report of 24 June 2023 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
What inspectors found, January 2020
Rated Requires Improvement; inspectors found kind and responsive care, but repeated safeguarding and notification failures meant the home was not always safe or well-led.
This was an unannounced inspection carried out over three days in August 2019. The inspector spoke with people living in the home, a relative, staff and visiting healthcare professionals. They also checked care records, medicines records, staff files and quality checks.
The home was rated Good for Effective, Caring and Responsive. People were treated with respect, supported to make choices, helped with their health and nutrition, and offered more structured activities than at the previous inspection.
Safe and Well-led were rated Requires Improvement. Two safeguarding concerns had not been referred to the local authority, and some incidents had not been reported to CQC as required. There were also minor medicines recording issues and delays completing some staff induction records.
The overall rating was Requires Improvement, the same as at the previous inspection published in August 2018. The home had received this rating at two consecutive inspections. CQC said it would discuss improvements with the provider and monitor progress.
Kind and respectful staff
People, relatives and visiting professionals spoke positively about staff. Inspectors saw that staff treated people with respect and protected their privacy and dignity.
“People described the staff as, "Nice," "Very good" and "Alright.” from the report
Choice and independence
People were involved in decisions about their care and in running parts of the home. Staff supported daily living skills and encouraged people to be as independent as possible.
“Staff promoted people's independence and daily living skills, including involving people in cooking and cleaning their bedrooms.” from the report
Health and nutrition support
People had access to health professionals and regular health checks. Their nutrition and hydration needs were recorded, and weights were monitored.
“People were supported to eat and drink enough.” from the report
More activities and staff consistency
Since the previous inspection, people had access to more structured activities and there was greater consistency among regular staff.
“There had been some improvements in the consistency of the regular staff team.” from the report
Safeguarding referrals were missed
seriousTwo incidents had not been referred to the local authority safeguarding team. The same problem had also been found at the previous inspection, so it had not been fully resolved.
“However, referrals had not been made for two incidents that had occurred.” from the report
Some incidents were not reported to CQC
seriousA small number of incidents were not notified to CQC as required. This was a breach of Regulation 18 and led to enforcement action.
“They had sent this information in the majority of cases, but we found a small number of incidents had not been notified to CQC as required.” from the report
Medicines records needed tightening
needs fixingThe systems for giving medicines were in place, but there were minor recording problems for medicines with extra storage and monitoring requirements.
“There were some minor record-keeping issues in relation to these particular medicines.” from the report
Staff induction delays
needs fixingChanges in the training department caused paperwork to go missing and delayed completion of some staff members' induction assessments.
“This had resulted in paperwork going missing and delays in the completion of some staff member's Care Certificate inductions.” from the report
Care plan information was not always current
minorSome outdated information remained after care plans were updated. This could create inconsistencies in the information staff used to support people.
“On occasions, outdated information was not fully removed from the care and support plan, when new updates were added.” from the report
- 01What changes have you made to ensure every safeguarding concern is referred to the local authority without delay?
- 02What checks now confirm that all incidents which must be reported to CQC are notified on time?
- 03How have you improved the recording and auditing of medicines with additional storage and monitoring requirements?
- 04Have all staff completed and had their induction assessments signed off, and how are missing training records prevented?
- 05How do you make sure outdated information is removed whenever a person's care plan is changed?
This was an unannounced scheduled inspection that looked at the overall service and all five CQC questions, including the care provided and the premises. This explanation was written from the published report of 28 January 2020 by an AI system and checked against the report text: every quoted line appears in the report. It is a guide to the report, not a substitute for it. Read the full report on cqc.org.uk.
Every inspection of Hawthorn House
6 rated inspections over 9 years: the service has improved, from Requires improvement to Good.
- June 2023Goodcurrent ratingup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- January 2020Requires improvementstayed Requires improvementSafe: Requires improvementWell-led: Requires improvement
- August 2018Requires improvementdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2016Goodup from Requires improvementSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- September 2015Requires improvementstayed Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- December 2014Requires improvementSafe: Requires improvementEffective: Requires improvementCaring: GoodResponsive: GoodWell-led: Requires improvement
- August 2013
Report published without a new overall rating.
- March 2013
Report published without a new overall rating.
- April 2011
Report published without a new overall rating.
- November 2010
Registered with the Care Quality Commission on 11 November 2010.
Ratings and report dates from the Care Quality Commission, Open Government Licence v3.0. A home can also be visited without a new rating being published, so the timeline shows published inspections.
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