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Hawthorn House Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 11 November 2020

About the service

Hawthorn House is a residential care home providing personal and nursing care to people aged 65 and over. At the time of the inspection there were 19 people living in the service. The service can support up to 22 people.

People’s experience of using this service and what we found

We found ongoing shortfalls in the management of the safety and quality of the service. Checks in place were not effective which had led to new and continued breaches of regulations.

The provider’s approach to assessing and managing environmental and equipment-related risks was inconsistent and identified risks were not always addressed. Action had not been taken to address longstanding risk associated with Legionella’s.

Staff were not up to date in safety-related training including medicines and there were no systems in place to assess their competency in this area.

The registered manager did not adopt a systematic approach to determining staffing levels based on people’s changing needs.

We have made a recommendation about safe staffing levels.

People’s consent had not always been appropriately sought and staff were unclear about the levels of restrictions in place for some people. People were not supported to have maximum choice and control of their lives and staff did not support them in the least restrictive way possible and in their best interests. The policies and systems in the service did not support this practice.

Despite our concerns, the culture in the service was warm and welcoming. We received positive feedback from people and their relatives about the care they received.

For more details, please see the full report which is on the CQC website at

Rating at last inspection and update

The last rating for this service was requires improvement (published 04 July 2019) and there were multiple breaches of regulation. The provider completed an action plan after the last inspection to show what they would do and by when to improve. At this inspection we found improvements had been made in some areas and not enough in others and the provider was still in breach of some regulations.

Why we inspected

We carried out an announced comprehensive inspection of this service on 30 May and 03 June 2019. Breaches of legal requirements were found. We undertook this focused inspection to check they had followed their action plan and to confirm they now met legal requirements. This report only covers our findings in relation to the Key Questions Safe and Well-led which contain those requirements.

The ratings from the previous comprehensive inspection for those key questions not looked at on this occasion were used in calculating the overall rating at this inspection. The overall rating for the service has not changed. This is based on the findings at this inspection.

You can read the report from our last comprehensive inspection, by selecting the ‘all reports’ link for Hawthorn House on our website at


We are mindful of the impact of the COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

We have identified breaches in relation to managing risks and the safe management of medicines, consent and the running of the service at this inspection.

Please see the action we have told the provider to take at the end of this report.

Follow up

We will meet with the provider following this report being published to discuss how they will make changes to ensure they improve their rating to at least good. We will work with the local authority to monitor progress. We will return to visit as per our re-insp

Inspection areas


Requires improvement

Updated 11 November 2020

The service was not always safe.

Details are in our safe findings below


Requires improvement

Updated 4 July 2019

The service was not always effective.

Details are in our Effective findings below.



Updated 4 July 2019

The service was caring.

Details are in our Caring findings below.


Requires improvement

Updated 4 July 2019

The service was not always responsive.

Details are in our Responsive findings below.



Updated 11 November 2020

The service was not well-led.

Details are in our well-Led findings below.