Hawthorne Nursing Home

People were supported with a wide range of needs including dementia, mobility support, pressure care, end‑of‑life care, Parkinson’s disease and the administration of time‑critical medicines.

We identified concerns around safety and governance. Environmental risks were not consistently managed, including fire safety arrangements, damaged fixtures and equipment that could not be cleaned effectively. Actions from fire risk assessments had not all been completed. These issues increased risks to people’s safety.

Infection prevention and control practices were not consistently effective. We found poor cleaning of equipment and damaged items, such as pressure cushions and mattress covers, that could not be cleaned effectively. This placed people at increased risk of infection.

People’s care records were not always clear or consistent. Some care plans and risk assessments lacked sufficient detail or contained contradictory information. This meant staff did not always have clear guidance on how to manage risks or respond to changes in people’s needs.

Medicines were stored securely and audits were in place. However, medicines management was not consistently safe, including gaps in infection control practices during administration and incomplete guidance for some ‘as required’ medicines. This increased the risk of unsafe medicines practices.

The service had experienced several recent changes in management with a change in manager between the first and second day of inspection. While people and relatives spoke positively about the management team, quality assurance systems were not yet effective. Leaders had not identified or addressed all the risks found during this inspection, including those relating to the environment, infection control and care planning. During the recent disruptions in management, leaders had not always maintained effective oversight of the running of the service. Some improvements had been made between the 2 inspection days.