Inspection on 23/08/05 for 26 Henley Way

This inspection was carried out on 23rd August 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

26 Henley Way 19/03/09

26 Henley Way 07/02/07

26 Henley Way 28/02/06

26 Henley Way 02/02/05

26 Henley Way 13/10/04

26 Henley Way 19/03/04

26 Henley Way 30/09/02

Similar services:

Hillside

Applegarth

122 Scorer Street

Jubilee Villa Care Home

Thornham Grove

Beech Lodge

8 Thorndale Road (Homefield College)

Hunter`s Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 26 Henley Way West Hallam Derby DE7 6LU Lead Inspector Tony Barker Unannounced 23rd August 2005, 2.10pm The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 26 Henley Way Address West Hallam Derby DE7 6LU Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0115 9441946 0115 9441946 United Response Lorraine Hirst Care Home 3 Category(ies) of 3 - Learning Disability registration, with number of places 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 2/2/05 Brief Description of the Service: 26 Henley Way is a detached house in a small village development. Service users are provided with adequate accommodation and single rooms. There is a reasonably-sized rear garden. The Home offers personal and social care to people with a severe learning disability with associated conditions that include autism and sensory disability. Activities are planned to meet individual needs. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The time spent on this inspection was 4.25 hours and was a routine unannounced inspection. The last inspection took place in February 2005 and was an unannounced inspection. This inspection was the inspector’s first visit to the Home. The Manager was spoken to, records were inspected and there was a tour of the premises. Two service users’ records were examined as part of the case tracking method. Service users’ learning and physical disabilities were such that they were unable to speak except on a single word level. However, they had varying degrees of non-verbal communication with the inspector. The focus of this inspection was on progress made on the requirements and recommendations made, and those standards not assessed, at the last inspection. What the service does well: What has improved since the last inspection? What they could do better: Certain aspects of the Home’s recording systems must be improved. These include the need to regularly review risk assessments; record the food that service users eat; record contacts with all health professionals; sign and date all records; improve the recording in staff rotas and provide a written policy/procedures on infection control. Additionally, all records required by Regulation must be available for inspection at all times and an annual development plan must be provided. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 6 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 & 5 Service users’ needs were providing an ongoing basis for care provided. Each service user had a written contract with the Home specifying the terms and conditions of their residence. EVIDENCE: The three service users at the Home were admitted in the late 1980’s and no original documentation was available from that time. Service users’ files contained detailed assessments of need and extensive individual care plans. These assessments and plans were being kept under review – except for some risk assessments. Service users’ files showed no evidence that the potential restrictions on service users’ ability to make choices, to have freedom of choice and decision making opportunities had been considered or discussed with service users or their representative. One service users’ contract between the funding authority and United Response was still not available although a second service user’s contract had been obtained since the last inspection. There was a written statement of terms and conditions between United Response and each service user. One of these was viewed and seen to make good use of pictorial symbols. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7 & 8 Service users’ needs were being fully considered and were reflected in their individual care plans. A good range of potential risks had been identified and plans put in place to minimise these. Service users were being helped to make decisions about their life. EVIDENCE: Two of the service users’ individual care plans were viewed as part of the case tracking – they included a behaviour management plan and other well worded and detailed risk assessments. However, not all of these risk assessments had been recently reviewed. Details such as the service users’ preferred name and their key worker had been added since the last inspection. Monthly reviews were being made of these care plans. However, the plans were still fully recorded in text – not in a format service users would necessarily understand. Shift plans set out daily tasks for staff and were seen to provide a good learning guide for staff. Some records were not signed or dated. All of the service users had difficulty communicating their needs and wishes although one services user had good comprehension abilities and does clearly make choices and decisions about everyday matters. The person-in-charge described how individualised methods had been developed to enable service 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 10 users to understand the expression of preferences and choices. A local advocacy agency was now providing a service to one service user. Service users were mainly able to make only few meaningful contributions to the day-to-day running of the Home. However, they were involved in discussions with their key worker prior to care plan review meetings in order to ensure that their views were made known. They then attended these meetings. However, these pre-meeting discussions were not being recorded on file. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 17 Service users were involved in fulfilling activities. They were offered a healthy diet and enjoyed mealtimes. EVIDENCE: All the service users were attending a day service as well as a ‘personal day’ spent one-to-one with staff from the Home. The latter, particularly, focussed on each individual’s assessed needs. It had been hoped that one service user would start an IT course at a local college but lack of staff able to drive to the college prevented this occurring. However, this particular service user does use a computer in the Home’s dining room. A menu dated April 2004 was seen to be satisfactory. Details of meals actually eaten had been recorded but only for a few weeks. The evening meal appeared tasty and attractive. Service users were seen to be enjoying it. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 & 20 Service users were receiving personal care in the way they prefer and require. Their health needs were being met though monitoring records were not always being made. Service users were generally being protected by the Home’s procedures for dealing with medicines. EVIDENCE: From observation and discussion with the person-in-charge it was clear that service users’ communication needs had been assessed and, wherever possible, were being met. As an example, each resident had a communication board in his bedroom individualised to his own level of comprehension – pictorial or makaton symbols. One service user had a sensory music centre in his bedroom and made use of the Home’s sensory room. The atmosphere in the Home was relaxed at the time of this inspection and positive interactions between staff and service users were seen. Records supported that service users’ health was being monitored. However, records were not being consistently made. For example, one resident’s last dental check was recorded at December 2003 even though each resident sees a dentist every six months, the person-in-charge confirmed. Specialist services were involved when needed – for example, the district nurse had advised over the management of a pressure sore on a service user’s heel. This service user’s mobility needs were being well met by appropriate equipment. However, the Home had no written policy on pressure relief. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 13 There were no service users who managed their own medication, and there had been little medication prescribed on a regular basis to the service users. At the time of this inspection only creams and some liquid medication was being administered – apart from occasional paracetamol tablets, as and when required. Recording practices on Medication Administration Record (MAR) sheets had improved since the last inspection as typed labels from the pharmacy were now being used. However, the number of items received were being dated but not ‘signed in’. Records were up-to-date and accurate and other aspects of medication practice were satisfactory. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) This section was not assessed. EVIDENCE: 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,29 & 30 Service users were living in a comfortable and safe environment. Specialist equipment was available to enable one service user with a physical disability to maximise his independence. Standards of hygiene and cleanliness were satisfactory though the absence of a written policy/procedures on infection control could lead to Health and Safety problems. EVIDENCE: There was evidence of ongoing work to maintain the premises. The building was being painted externally at the time of this inspection and a fire safety sprinkler system had been installed. There were no environmental defects found at this inspection. Specialist equipment was in place for one service user who used a wheelchair. This addressed his bathing needs, transfers and skin integrity. This equipment was being serviced appropriately. Facilities within the laundry room were adequate and the washing machine had a sluicing programme. However, the person-in-charge was not aware of there being a written infection control policy/procedure in place. The Home was clean and free from odours. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 16 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 & 35 Service users were being supported by adequate numbers of staff though a turnover of new starters was causing problems. EVIDENCE: 40 of the staff had a National Vocational Qualification (NVQ) at level 4 or above. The person-in-charge said that there were between one and three staff – normally two – on duty at all times. Staffing levels were safe, she added. Staff rotas indicated that, although satisfactory staffing levels were being maintained, a large number of shifts had been worked by agency staff. Also, the Home’s own staff had been working a significant amount of overtime – they had worked a total of 240 hours in excess of their contract hours during the month of July. The person-in-charge stressed that this overtime would reduce once the latest member of staff had completed her six-week induction in mid-September 2005. She said that turnover of new staff had been high but there was now a full staff group. 12 hours a week additional funding had been acquired for one resident. Rotas did not record staff surnames and use of the 12-hour clock made some entries confusing. Staff training records could not be accessed. It was therefore not possible to confirm whether mandatory training, at appropriate frequencies, was being provided to staff. The person-in-charge stated that staff were being provided 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 18 with twice-yearly fire training. There was no at-a-glance record of staff training. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 There was some monitoring of the quality of life experienced by service users. The health, safety and welfare of service users was being promoted and protected. EVIDENCE: The person-in-charge said that an annual plan had been discussed and was still being written - in the form of a ‘Service Plan’ – as part of the Home’s quality assurance system. She confirmed that United Response had an extensive quality assurance system and the Area Manager contributed to this on a monthly basis. Service users were not able to meaningfully contribute to quality monitoring. The Records File showed that Health & Safety checks were being made. The Pre-Inspection Questionnaire indicated that equipment was being maintained and serviced appropriately. No Health & Safety problems were found during the tour of the premises. 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x 2 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 3 2 Standard No 11 12 13 14 15 16 17 x 3 x x x x 2 Standard No 31 32 33 34 35 36 Score x x 2 x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 26 Henley Way Score 3 2 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 21 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard 2 Regulation 17(1) Sch3.3(q) Requirement The Manager must ensure that each Service User, or their representative, has had the opportunity to discuss their rights to choice, freedom and decision-making while staying in the Home. The outcome must be recorded in each Service Users records.(Previous timescale was 4/4/05). Details of the purchasing contract relating to the Service Users accommodation must be kept in the Home and be available for inspection.(This requirement should have been addressed from the inspection report dated 11 November 2003) The registered person must ensure that risk assessments are kept up-to-date. A record of the food that service users actually eat must be consistently recorded so as to ensure that diets are adequately monitored. Consistent records must be kept of all treatment received from a health professional. All handwitten records must be dated and signed. Any Timescale for action 1 November 2005 2. 5 5(3) 1 December 2005 3. 4. 6 17 15(2)(b) 17(2) Sch 4.13 1 November 2005 1 November 2005 1 November 2005 1 November Page 22 5. 6. 19 20 13(1)(b) 13(2) 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 7. 30 13(3) 8. 33 17(2) Sch 4.7 9. 35 17(3)(b) Sch4.6(g) 24(1) 10. 39 handwritten changes must also be countersigned and dated. The registered persons must ensure that a written policy/procedures on infection control is put in place and staff are made fully aware. The registered persons must ensure, through appropriate recording of staff names and use of the 24-hour clock, that staff rotas are clear and unambiguous. Records listed in Schedule 4, including staff training records, must be available for inspection at all times. The Registered Providers must develop an annual plan for the Home indicating aims and objective for 2004 (2005).(This Standard should have been addressed from the inspection report dated 11 November 2003) 2005 1 January 2006 1 November 2005 1 November 2005 1 January 2006 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 6 Good Practice Recommendations Each service user’s plan of care should be recorded in a language and format suitable to each service user and the relevant service user should hold a copy. However, if this is inappropriate the Manager must record the reason for this within the care plan. (This was a recommendation from 2 February 2005) All records should be signed and dated. The outcome of discussion withs service users prior to care plan review meetings should be recorded on file. Menus should be reviewed periodically - seasonally for example. A policy/procedure should be written regarding the promotion of tissue viability. 50 of staff should achieve a National Vocational C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 23 2. 3. 4. 5. 6. 6 8 17 19 32 26 Henley Way 7. 8. 9. 10. 11. 33 33 35 35 41 12. 43 Qualification (NVQ) to level 2 or above by 31 December 2005. The registered persons should ensure that staff do not work excessive hours and use of agency staff is kept to a minimum. The manager should re-establish the regularity of staff team meetings. (This recommendation from 13 October 2004 was not assessed) The manager should retain copies of staff appraisals at the home.(This recommendation from 13 October 2004 was not assessed) The registered persons should consider providing a ‘training matrix’ staff group record to give an at a glance overview of staff training. The registered person should record situations where physical restraint has been employed separately from accidents and incidents, to assist with better monitoring.(This recommendation from 11 November 2003 was not assessed) Evidence of business planning should be available for inspection.(This recommendation from 11 November 2003 was not assessed) 26 Henley Way C02 C52 S200121 Henley Way V244678 220805 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection South Point, Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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