CARE HOME ADULTS 18-65
Henley Way (26) West Hallam Derby Derbyshire DE7 6LU Lead Inspector
Anthony Barker Unannounced Inspection 28th February 2006 01:40 Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 1 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 Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 2 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 Stationery 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. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Henley Way (26) Address West Hallam Derby Derbyshire DE7 6LU (0115) 9441946 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) None United Response Lorraine Hirst Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 23rd August 2005 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. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The time spent on this inspection was 5 hours and was a routine unannounced inspection. The last inspection took place in August 2005 and was an unannounced inspection. The Manager was present for a short while at the beginning of this inspection but had to leave due to ill health. For this reason, not all the core standards were assessed. The United Response Service Manager and one member of staff were spoken to and records were inspected. There was no 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:
Service users’ rights to choice, freedom and decision-making, while staying in the Home, must be discussed with them, or their representative, and the outcome recorded in their records. Risk assessments must be kept up-to-date
Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 6 and a record of the food that service users actually eat must be consistently recorded. Entries on Medicine Administration Record (MAR) charts must be consistent with records held elsewhere and all handwritten records must be dated and signed and any handwritten changes must also be countersigned and dated. A recognised code or a signature must be entered on MAR charts at all times. The registered person must maintain, within the Home, a record of any complaints made about the Home. 50 of staff must achieve a National Vocational Qualification (NVQ) to level 2 or above. The registered person must ensure that staff are provided with fire precaution training at a frequency no less that twice a year, if they undertake night shifts. 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. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 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 the following standard(s): No standard in this section was fully assessed. Each service user had a written statement of terms and conditions with United Response and an individual written contract from their funding authority. EVIDENCE: Service users’ files still showed no evidence that any limitations on service users’ freedom of choice, liberty of movement and power to make decisions had been considered or discussed with service users or their representative. This is a Regulation requirement. The Service Manager said he would check with the Home’s Registered Manager. Other aspects of standard 2 were not assessed on this occasion. Contracts between each service user’s funding authority and United Response were now in place. Other aspects of standard 5 were not assessed on this occasion. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 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 the following standard(s): No standard in this section was fully assessed. Service users were benefiting from consideration of improved involvement in the running of the Home. EVIDENCE: Two of the service users’ individual care plans were viewed as part of the case tracking method. It was noted that, as at the last inspection, not all of the risk assessments had been recently reviewed although some improvement had taken place since the last inspection. Care plans were still fully recorded in text – not in a format service users would necessarily understand. The Service Manager stated that this was not appropriate due to service users’ level of disability. He agreed to record this decision, and reasoning, on each individual file. Other aspects of standard 6 were not assessed on this occasion. Minutes of the last team meeting showed that the Home was exploring more ways of involving service users in the day-to-day running of the Home. An example was given of involving them in fund-raising activities. Other aspects of standard 7 were not assessed on this occasion. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 10 Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 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 the following standard(s): No standard in this section was fully assessed. Service users were given opportunities for personal development. EVIDENCE: Minutes of the last team meeting made reference to staff not having rushed a particular service user, due to time constraints, and showed awareness of the danger of deskilling individuals by staff undertaking tasks that service users were capable of doing themselves. Other aspects of standard 11 were not assessed on this occasion. The Home was operating a three-week rolling menu system last reviewed in November 2005. A record of meals actually eaten was only available for two weeks in January 2006. This inconsistent recording was found at the last inspection. Other aspects of standard 17 were not assessed on this occasion. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 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 the following standard(s): 20 Service users were not being fully protected by the Home’s procedures for dealing with medicines. EVIDENCE: The Service Manager showed the Inspector a new electronic communication board for one of the service users. This was currently being used by staff to communicate with the service user but it was hoped that the device would eventually be used by the service user to communicate with staff. It was stated that a speech therapist was also involved with this service user. Other aspects of standard 18 were not assessed on this occasion. Records supported that service users’ health was being monitored and records of health checks were now being consistently made. However, with regard to one service user’s Medical Profile these health appointments were not all being recorded. With regard to the management of pressure sores, the Home’s ‘Quality Assurance Manual’ included reference to the ‘visual checking for signs of injury or infection’. Other aspects of standard 19 were not assessed on this occasion. One service user’s medicine administration record (MAR) chart was examined. Items of medication received were being dated and ‘signed in’. A change of dosage for eye gel had been signed against but with no date or
Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 13 countersignature. The Service Manager produced a list of this service user’s medication at November 2004 – it did not include one item of medication currently being administered. Diagonal ‘slashes’ were being frequently entered when medicine was due to be administered but these ‘codes’ were not explained in the ‘key’ at the base of the MAR chart. A number of gaps were found on the MAR chart. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 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 the following standard(s): 22 & 23 Service users were benefiting from an appropriate complaints procedure although no complaints record was being maintained. They were being protected from abuse. EVIDENCE: The Home’s complaints procedure was displayed in the hallway and was satisfactory. Staff spoken to stated that there had been no complaints received by the Home and the Service Manager confirmed this. The complaints record could not be found. The Service Manager stated that the Home’s Registered Manager had attended a Derbyshire County Council training course on Adult Protection as well as United Response-funded external training on the same topic. United Response has an appropriate written procedure that is to be followed when there is suspicion of adult abuse. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 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 the following standard(s): No standard in this section was fully assessed. Service users were being provided with hygienic accommodation. EVIDENCE: The Home’s written Infection Control policy and staff Training Manual was examined. The Service Manager stated that the Manual would be provided to staff at the next team meeting, due soon. The Home was clean and free from odours at the last inspection. Other aspects of standard 30 were not assessed on this occasion. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 16 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33 & 35 Service users were not being supported by an adequately qualified staff group. However, they were being supported by an effective staff team. Service users’ safety was being compromised by a staff group who had received inadequate fire training. EVIDENCE: One member (25 ) of care staff had a National Vocational Qualification (NVQ) at level 2. The Service Manager stated that one other staff member was to be put forward for NVQ level 2 soon. The staff rota for March 2006 was examined. Full staff names were being recorded and the 24 hour clock was in use – this made the rota more clear and unambiguous. A significant number of relief and agency staff hours were still being used. A member of care staff said that these hours were to cover for staff sickness and two vacancies, the latter being approximately 1.5 full-time equivalent hours. The Service Manager stated that the use of agency staff has just ‘peaked’, mainly due to staff sickness. He spoke of an aim to ‘over recruit’ in order to provide peripatetic staff instead of using agency staff. He said that the hours worked by permanent staff, in excess of their contracted hours, were being monitored to ensure that staff were not working excessive hours. The minutes of recent staff team meetings showed that these were being held at regular intervals.
Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 17 The file of a staff member who started work in August 2005 was examined. All mandatory training had been provided except for fire training. The most recent ‘matrix’ of staff training was examined and this indicated that a member of staff who started in October 2003 had been provided with no fire training. All other staff had received their last fire training in October 2004. It was noted that one senior staff member had had an appraisal in January 2005. Other aspects of standard 36 were not assessed on this occasion. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 18 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 42 The health, safety and welfare of service users was being promoted and protected. EVIDENCE: The Home’s current Service Plan was examined – it contained 17 goals with a number of “Ongoing” entries under “Timescale”. Other aspects of standard 39 were not assessed on this occasion. A section in the Home’s Accident/Incident folder has been specifically set aside to record situations where physical restraint has been employed - to assist with better monitoring. Other aspects of standard 41 were not assessed on this occasion. A notice was displayed on the inside of the dining room patio windows warning staff about the raised flagstones on the patio and suggesting sensible measures to take to minimise injury to service users. The Home’s Certificate of Employer’s Liability Insurance was conspicuously displayed and was current. No Health & Safety problems were found at this inspection.
Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 19 Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X X X X X X 3 X Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 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 YA2 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). The registered person must ensure that risk assessments are kept up-to-date. (Previous timescale was 01/11/05). A record of the food that service users actually eat must be consistently recorded so as to ensure that diets are adequately monitored. (Previous timescale was 01/11/05). All handwritten records must be dated and signed. Any handwritten changes must also be countersigned and dated. (Previous timescale was 01/11/05). Entries on Medicine Administration Record (MAR) charts must be consistent with records held elsewhere.
DS0000020012.V279838.R01.S.doc Timescale for action 01/11/05 2. YA6 15(2)(b) 01/05/06 3. YA17 17(2) Sch 4.13 01/04/06 4. YA20 13(2) 01/04/06 5. YA20 13(2) 01/04/06 Henley Way (26) Version 5.1 Page 22 6. YA20 7. YA22 8. 9. YA32 YA35 When prescribed medicines are not administered to a service user a code must be entered, instead of a signature, that corresponds to a MAR chart key. ie. all entries must be explicit. A code or a signature must be entered at all times - there must be no gaps. 17(2) Sch The registered person must 4.11 maintain at all times, within the Home, a record of complaints made about the Home. 18(1)(a)(c) 50 of staff must achieve a National Vocational Qualification (NVQ) to level 2 or above. 23(4)(d) The registered person must ensure that staff are provided with fire precaution training at a frequency no less that twice a year, if they undertake night shifts. 13(2) 01/04/06 01/04/06 01/10/06 01/06/06 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 YA6 Good Practice Recommendations Each service users 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. (This recommendation from 23 August 2005 was not assessed) The outcome of discussion with service users prior to care plan review meetings should be recorded on file. (This recommendation from 23 August 2005 was not assessed) Health appointments should be recorded on service users’ Medical Profiles. The registered persons should ensure that the use of agency staff is kept to a minimum. (This was a
DS0000020012.V279838.R01.S.doc Version 5.1 Page 23 2. 3. 4. 5. YA6 YA8 YA19 YA33 Henley Way (26) 6. YA39 recommendation from 23 August 2005) The Home’s Service Plan should include actual timescales to enable it to be more measurable. Henley Way (26) DS0000020012.V279838.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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