CQC report explained · a nursing home
What the CQC found at Hawthorne House
Rated Requires improvement: inspectors found the home was not performing as well as it should and told it what to change.
What inspectors found, February 2024
Hawthorne House was rated Requires Improvement; inspectors found unsafe gaps in risk management, medicines, staffing and oversight.
This was an unannounced, focused inspection after concerns about risks in people's care and medicines. Inspectors visited the home, spoke with people, relatives and staff, reviewed 17 care plans and five medicines records, and observed a medicines round.
The home was not always safe. Records did not consistently show that checks and care had happened. Medicines were not always given or recorded safely. Staffing levels and arrangements meant some people experienced delays or lacked supervision. Infection control and recruitment checks were good.
The home was also not always well led. Checks did not reliably find problems or ensure they were put right quickly. The overall rating fell from Good at the previous inspection, published in May 2021, to Requires Improvement. The provider must make improvements and send CQC an action plan.
Infection control
Staff followed good infection prevention processes. Protective equipment was available and clinical waste was disposed of safely.
“The prevention and control of infection was managed safely. Good infection prevention and control processes were followed.” from the report
Respectful staff
People generally spoke positively about staff and said they were treated with respect.
“People told us staff treated them with respect.” from the report
Mental capacity safeguards
Mental capacity assessments and liberty safeguards were in place where needed. Staff understood which people had these arrangements and why.
“We found the service was working within the principles of the MCA and if needed, appropriate legal authorisations were in place to deprive a person of their liberty.” from the report
Recruitment checks
The home carried out references and criminal record checks before staff started work.
“Staff had been recruited following a number of checks to ensure they were safe to work with people.” from the report
Risk checks were not reliable
seriousRecords did not show that some important checks had happened, including repositioning, blood sugar monitoring and frequent checks for someone at risk of falling. Worn walking-frame parts also increased falls risk.
“Records failed to show that checks detailed in people's care plans were completed in a timely manner.” from the report
Medicines were not always safe
seriousThere were gaps in medicines records, missing paperwork for hidden medicines, incomplete storage checks and risks with medicines given through feeding tubes. Some staff also lacked important medicines knowledge.
“People did not always receive their medicines safely or as prescribed. Records were not sufficiently clear to show how medicines had been managed.” from the report
Staffing affected care
seriousStaffing arrangements meant some people had delayed personal care or pain relief, lacked supervision, or could not attend planned activities.
“Staffing arrangements meant people some people were placed at risk of unsafe care.” from the report
Management checks missed problems
seriousQuality checks did not consistently identify or address risks. This included unsafe equipment, medicines problems, staffing issues and unexplained injuries.
“The provider's systems and processes to monitor the quality of the service provided were not always effective.” from the report
- 01What has been done to make sure repositioning, blood sugar checks and falls monitoring are recorded every time?
- 02How are medicines now checked, including medicines hidden in food, medicines given through PEG tubes and medicines that are out of stock?
- 03How will you ensure there are enough staff on every unit so people receive personal care, pain relief, supervision and planned activities without delay?
- 04What changes have been made to quality audits so they identify faulty walking frames, uncalibrated equipment and medicines risks promptly?
- 05How are unexplained injuries investigated, and how do you show that learning from incidents has been put into practice?
This was a focused inspection of Safe and Well-led only; the other key-question ratings were carried over from the previous inspection. This explanation was written from the published report of 1 February 2024 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, May 2021
Rated Good overall, but Safe Requires Improvement; Hawthorne House improved from Inadequate and is no longer in Special Measures.
Inspectors visited on 23 and 25 March 2021. They spoke with people, relatives, staff and health professionals. They reviewed 35 care records, medicines records, staff files and management records, and observed care.
They found improvements in staffing, medicines, safeguarding, care planning and management. People said staff were kind and that they felt safe. However, two cabinet locks did not work and three walking frames had worn rubber feet, increasing safety risks. These problems were corrected immediately.
The overall rating was Good. Effective, Caring, Responsive and Well-led were rated Good. Safe was rated Requires Improvement, which means some safety arrangements were not always reliable and there was limited assurance about safety. The home had previously been rated Inadequate and in Special Measures, but inspectors found it was no longer in breach of regulations and had left Special Measures.
Major improvement
Inspectors found that the home had improved since the previous inspection, including staffing, safeguarding, medicines and management.
“At this inspection we found improvements had been made and the provider was no longer in breach of regulations.” from the report
Kind and respectful staff
People and relatives described staff positively. Inspectors also saw warm, friendly interactions and a welcoming atmosphere.
“People and relatives told us staff were kind.” from the report
Improved staffing
People and relatives said staff availability had improved. Staffing levels were adjusted when people's needs changed.
“The registered manager had reviewed people's individual needs and increased staffing levels.” from the report
Faulty cabinet locks
seriousTwo cabinets containing thickening powder had locks that did not work. The manager replaced the cabinets during the inspection.
“At this inspection lockable cabinets were in place throughout the service however we found two locks did not work.” from the report
Worn walking-frame feet
seriousThree walking frames had rubber feet worn down to the metal. Inspectors said this increased the risk of falls, and replacements were arranged immediately.
“We saw the rubber ferrules on three walking frames had worn down to the metal.” from the report
- 01How often are cabinet locks, walking frames and other equipment now checked, and who reviews the results?
- 02What checks are in place to prevent thickening powder and other items linked to choking risks from being stored insecurely?
- 03How will you show that the improvements made since May 2020 have been maintained?
- 04How do you decide when staffing levels need to be increased if a person's needs change?
- 05How are relatives kept informed about changes in care, concerns or incidents?
This was a planned inspection of all five key questions, including infection prevention and control under Safe; inspectors also reviewed records, observed care and gathered views from people, relatives, staff and professionals. This explanation was written from the published report of 1 May 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 Hawthorne House
4 rated inspections over 5 years: the service has held its Requires improvement rating throughout.
- February 2024Requires improvementcurrent ratingdown from GoodSafe: Requires improvementEffective: GoodCaring: GoodResponsive: GoodWell-led: Requires improvement
- May 2021Goodup from InadequateSafe: Requires improvementWell-led: Good
- May 2020Inadequatedown from Requires improvementSafe: InadequateEffective: Requires improvementCaring: Requires improvementResponsive: Requires improvementWell-led: Inadequate
- March 2019Requires improvementSafe: Requires improvementEffective: GoodCaring: GoodResponsive: Requires improvementWell-led: Requires improvement
- July 2017
Registered with the Care Quality Commission on 12 July 2017.
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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What to check when you visit
At least 100 live-in carers within about an hour of Coventry
These are self-employed carers on PrimeCarers, the introductory agency that runs this directory. Each has a profile with their own rates and reviews from families, and you choose who to talk to.
Most charge £950 to £1,260 a week. 80 can care for a couple. 11 years' experience on average.
“If you bump into her in the night on her way to the bathroom she will still inquire how you are and if everything is alright.”
“My mum would not eat, drink, bath nor sleep without her. In short, she was FAMILY and we loved her dearly”
Every carer has had an enhanced DBS check in the last 18 months, ID and right-to-work checks and an online interview. Their skills and training are for you to check with them. Carers set their own rates, and who is free changes week to week.