CQC report explained · a residential care home
What the CQC found at Hawthorn Manor Residential Home
Rated Good: inspectors found the home performing well and meeting their expectations.
What inspectors found, October 2022
Rated Good; inspectors found safe, kind and personalised care, with some records needing improvement.
This was an unannounced inspection over three days. Inspectors spoke with people living at the home, relatives, staff and visiting professionals. They reviewed care records, staff recruitment and training files, medicines arrangements, audits and infection control.
All five areas were rated Good: Safe, Effective, Caring, Responsive and Well-led. People said they felt safe, received help promptly and were treated kindly. Inspectors found enough staff, safe medicine administration, good support with food and health needs, personalised care plans, activities and positive management.
There were some record-keeping problems. A nutritional supplement was not recorded on one medicines administration sheet, some mental capacity paperwork was inconsistent, and technical problems had left some care plans out of date. The provider acted immediately on the first two issues and planned to move to a different care planning system.
The home was also rated Good at its previous inspection, published on 11 October 2018. The report says the new manager was applying for registration at the inspection and had since become registered.
People felt safe
People said they felt safe and did not wait long for help. Inspectors also found that known risks, including falls, skin problems and emergencies, were managed carefully.
“People told us there were enough staff to keep them safe and they did not have to wait long for help from staff when they called on their call bells.” from the report
Kind and respectful care
People and relatives spoke warmly about staff. Inspectors saw staff supporting people patiently and protecting their dignity and privacy.
“We saw kind and caring support being provided.” from the report
Personalised support
Care plans included people's preferences, histories and interests. Staff adapted support to individual needs, including communication needs and food preferences.
“People's care plans were individualised and person-centred.” from the report
Good activities and relationships
People could join group activities or receive one-to-one time in their rooms. The home supported visits and links with the local community.
“People had access to a wide range of activities that were appropriate and relevant to their interests.” from the report
Responsive management
The management team listened to people, staff and professionals and acted quickly on issues raised. Audits were used to monitor areas such as falls, medicines and call bell responses.
“Managers were responsive and took swift action to put any shortfalls right.” from the report
One medicine record was incomplete
needs fixingA prescribed nutritional supplement was not recorded on one medicines administration sheet. The provider corrected this immediately, and inspectors said the person had received the supplement as instructed.
“One person had been prescribed a nutritional supplement but this was not being recorded on a medicines administration sheet.” from the report
Some mental capacity paperwork was inconsistent
needs fixingInspectors found inconsistencies in some mental capacity assessments. The provider took immediate action to put this right.
“However, we found some inconsistencies in how some documentation had been completed for some mental capacity assessments.” from the report
Care plan information was sometimes out of date
minorTechnical problems with the electronic care planning system meant some information was not current. Staff knew people's correct needs, and the provider planned to change systems.
“Although this had caused some information to be out of date on some care plans, staff knew people and the correct information” from the report
- 01Have all medicines and nutritional supplements been checked to make sure they are recorded correctly on administration sheets?
- 02What changes were made to the mental capacity assessment paperwork after the inspection?
- 03Has the replacement electronic care planning system been introduced, and how do you check that care plans are up to date?
- 04How do you make sure staffing levels reflect people's changing needs, including mental health support?
- 05How will you involve my relative in decisions about their daily care, activities and future end of life preferences?
This was an unannounced inspection covering all five CQC questions and infection prevention and control, with records, medicines, staffing, care and management arrangements reviewed. This explanation was written from the published report of 14 October 2022 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, February 2021
Inspected but not rated; inspectors found good infection control practice, but the admissions policy was not fully up to date.
This was an unannounced, targeted inspection on 18 January 2021. It was carried out after concerns were raised about infection prevention and control.
Inspectors found that the home was using protective equipment safely, supporting social distancing and managing visitors, admissions, testing and possible outbreaks. They were assured that infection control practice was keeping people safe.
The home’s infection control policy was not fully up to date. It did not clearly say that people without COVID-19 symptoms should also be isolated for 14 days after admission, unless they had already isolated elsewhere.
The home was inspected but not rated. This means the inspection looked specifically at infection prevention and control, rather than giving an overall quality rating.
Keeping people connected
Staff helped people spend time with friends while keeping social distancing in place. This was intended to reduce isolation.
“Staff supported people to spend time with their friends, while remaining safe.” from the report
Protective equipment
There was plenty of protective equipment, and staff used it safely and appropriately.
“There was a plentiful supply of personal protective equipment (PPE). Staff used PPE appropriately and safely.” from the report
Supporting bereavement
The home worked with people to plan how they wanted to remember and celebrate the lives of people who had died.
“The service was working with people to plan how they wanted to celebrate the lives of those who had died.” from the report
Admissions policy was unclear
needs fixingInspectors found no concerns with the home’s actual practice, but its written policy did not clearly cover 14-day isolation for people admitted without COVID-19 symptoms.
“Government guidance stated everyone admitted to the service should be isolated for 14 days, unless they have already undergone isolation in another setting.” from the report
- 01Has the admissions policy been updated to clearly require 14 days of isolation for people without COVID-19 symptoms, unless they have already isolated elsewhere?
- 02How does the home currently test people using the service and staff?
- 03How does the home manage visitors and social distancing while helping residents stay connected?
- 04What protective equipment is available, and how does the home check that staff use it safely?
- 05What is the home’s current plan for preventing and managing an infection outbreak?
This was an unannounced targeted inspection of infection prevention and control, so the home was inspected but not rated overall and the other care areas were not assessed in this report. This explanation was written from the published report of 13 February 2021 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 Manor Residential Home
3 rated inspections over 6 years: the service has held its Good rating throughout.
- October 2022Goodcurrent ratingSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
Read what inspectors found at Hawthorn Manor Residential Home →
- February 2021Inspected but not ratedSafe: Inspected but not rated
Read what inspectors found at Hawthorn Manor Residential Home →
- September 2020Inspected but not ratedSafe: Inspected but not ratedWell-led: Inspected but not rated
- November 2018Goodstayed GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- May 2016GoodSafe: GoodEffective: GoodCaring: GoodResponsive: GoodWell-led: Good
- September 2014
Report published without a new overall rating.
- July 2014
Registered with the Care Quality Commission on 31 July 2014.
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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