Inspection on 06/02/06 for Edward House

This inspection was carried out on 6th February 2006.

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 no outstanding requirements from the previous inspection report, but made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Edward House 31/10/06

Edward House 19/07/05

Edward House 09/12/04

Edward House 21/06/04

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

CARE HOME ADULTS 18-65 Edward House 14/16 Edward Street Werneth Oldham OL9 7QW Lead Inspector Sandra Bennett Unannounced Inspection 6th February 2006 12:00 Edward House DS0000005549.V271020.R01.S.doc Version 5.0 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 Edward House DS0000005549.V271020.R01.S.doc Version 5.0 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. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Edward House Address 14/16 Edward Street Werneth Oldham OL9 7QW 01616241908 0161 620 3550 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) Turning Point Mrs Christine Anne Mercer Care Home 17 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (9), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (8) Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The home is registered for a maximum of 17 service users to include: * up to 9 service users in the category of MD (Mental disorder excluing learning disability or dementia under 65 years of age). *up to 8 service users in the category of MD(E) (Mental disorder excluding learning disability or dementia over 65 years of age). A manager must be in place at all times who has the qualifications, skills and experience necessary for managing the service and registered with the Commission for Social Care Inspection. 19th July 2005 2. Date of last inspection Brief Description of the Service: Edward House is a large Victorian property, owned and managed by the charity Turning Point. The home is situated close to Oldham town centre, local amenities and public transport. Accommdation is provided in 12 single rooms, eight of which have ensuite. Two of these rooms also include a bath and shower. There are also three shared rooms, two lounges one of which is no smoking and a large dining room. There are ample communal toilets and bathrooms in addition to ensuite facilities. Attractive gardens are to the front of the property with patio garden areas to the rear. The home does not provide a lift, however most of the service users are physicaly able. Ground floor bedroms are available also an assissted bathroom which provides level access for those service users who may find stairs difficult or require assistance. Edward House is registered to provide care for up to 17 service users with enduring mental health problems and is a community based project. Their aim is to encourage service users to take an active part in the community through education, work based projects and community work. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unscheduled inspection took place on 6/2/06. During the inspection four service users were interviewed in private, as were three members of staff. Discussions also took place with the manager and acting deputy manager. Ten service user and relative questionnaires were left for completion, three were returned all were complimentary regarding the care they received. The inspector also undertook a selected tour of the building and scrutinised a selection of service user and staff records, as well as other documentation, including duty rotas, medication records and staff recruitment. What the service does well: What has improved since the last inspection? Since the last inspection three bedrooms have been redecorated. One-service user discussed with the inspector their choice in colours and refurbishment saying “My key worker helped me to choose what I wanted and also to keep my room clean and tidy”. A new carpet has been provided in one room. A computer has been allocated for service users personal use or to continue their training. The home does not operate a call system therefore a personal alarm has been provided for night staff and service users protection if needed. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 6 What they could do better: 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. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 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 Edward House DS0000005549.V271020.R01.S.doc Version 5.0 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): 2 A detailed assessment from health professionals ensures the home meets the needs of service users. EVIDENCE: Detailed assessments of service a user needs is obtained from health professionals prior to their admission. Social histories were on file to give staff an understanding of service users lives when transferring assessments into care planning. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 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): 6, 8. Service users files need to have a uniform approach with written work being signed and dated to ensure service users needs are continually met. Service users responsibility in maintaining their preferred lifestyle is promoted through decision making in the home, which aids their independent living skills. EVIDENCE: Examination of service users files found they identified their goals and aspirations and provided staff with guidelines on how these may be achieved within the service users capabilities. Case files of service users contained their licensing agreement, health care visits, and details of how their health and emotional needs should be addressed. Risk assessments were completed on all aspects of care and activities. The organisation of the filing and care planning system was being reviewed and updated. Reviews and care plans should also include dates and signatures of the person completing them. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 10 Files should be complied in a uniform manner ensuring an audit of the service users progress can be followed. Daily reports were detailed and reflected events of the service users day. Service users commented on regular community meetings to discuss ongoing developments in the home. One service user showed the inspector their bedroom, which had been recently redecorated and refurbished, and they had been encouraged to choose the colour and design. The service users said, “ My key worker helps me to keep my room tidy”. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 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): 11, 12. Service users are provided with opportunities for personal development, education and leisure, which are community based in order to promote their independence. Service users need to be consulted regarding their holiday entitlement in order to widen their environment and increase stimulation. EVIDENCE: Service users discussed their activities in the community both leisure and educational. Examples were given of keep fit classes, access to day care services for social activities and a computer class. A review of staffing structures in the main organisation Turning Point resulted in the temporary loss of the homes activity coordinator. Although staff attempted to maintain community involvement for service users this aspect has been for a short time depleted. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 12 However the service users informed the inspector that the activity coordinator was being brought back into the home, which they were very pleased about. This was validated through interviews with the management team. Each service user has an activity file were they record what they have been doing. Both the staff member and the service users make written comments in the file. A computer has been allocated in the dining area of the home in order for service user to practice their skills, take notes or complete minutes of their meetings if they wish. One service user said, “I would like to go on holiday but I don’t think we are going anywhere.” Standard 14 of the National Minimum Standards states long stay service users must be offered a as part of their basic contract price the option of a minimum seven day annual holiday outside the home which they have helped to choose and plan. Turning Point makes available to Edward House a caravan in order to provide for this. However this does limit the service users choices. At the time of this inspection no holidays had been planned. The home should give consideration to this in order to met service users need. Another service user said they liked living in the home and were able to go out when the wanted to and visit their personal hairdresser. Other comments included “I like to go to the local pub and bookmakers.” Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 13 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): 19, 20. Although recording systems need to be improved service users were satisfied that their physical and emotional needs were being met. Medication procedures were not sufficient to protect the interests of service users. EVIDENCE: The home is presently reviewing service users files. All health care needs and visits are recorded. Dates of reviews and care planning need to be recorded consistently and signed by the person completing them. The lack of these makes it difficult to assess an audit trail of service users progress. Service users were very complimentary on the support given by staff. Comments made included, “I like my key worker very much and can tell them anything”, also “My key worker helps me to go to the clinic, and reminds me what to do”, also “I feel staff support me and can go out when I want”. Examination of medication policies and procedures found that some improvement was needed in relation to record keeping, staff training, and risk assessments for those service users who wish to self medicate. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 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. Service users were confident they could raise concerns with staff and they would be listened to. EVIDENCE: Edward House maintain a logbook of complaints. Service users receive a copy of Turning Point complaints procedure. There is a space at the bottom of the leaflet for the Commission of Social Cares address to be added enabling the service user to contact the CSCI if they are dissatisfied with outcome of any investigation. The home must take a proactive approach to ensure this information is added to the leaflet. Service users did say they felt listened to if they had any concerns or complaints. This was evident through minutes of service user meetings. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 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): 26, 30 The home provides a homely atmosphere for service users, however certain areas required additional smoke/odour control and replacement furniture to ensure the safety and comfort of service users. Service users bedrooms were appropriately personalised. EVIDENCE: Edward House provides a homely environment and atmosphere for service users. Many of the bedrooms have been personalised with the service users being keen to show the inspector their bedrooms and discuss their responsibility in maintaining hygiene standards and personal laundry. A selection of rooms was inspected. One of which had been changed form a shared room to provide a separate living and bedroom space for the service user. A number of chairs in bedrooms were damaged or badly stained and required recovering or replacement. This had also been recognised by the manager had had been included in the homes refurbishment list. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 16 One service user showed the inspector their bedroom, which had recently been refurbished. Service users can choose from a variety of communal areas one of which is a no smoking lounge. All other areas of the home are affected and discoloured by smoking in the home. Although staff keep the home clean, tidy and redecorate has much has possible strong smoke odours remain. The home should undertake a review of the level at which extractor fans are functioning and its efficiency in maintaining a clean atmosphere and environment. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 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 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, 34, 35, 36. Effective staff supervision and communication systems in the home ensured the needs of service users were met. Recruitment procedures were not robust enough for the protection of service users. The number of staff who hold NVQ’s needs to be increased in order to maintain the positive outcomes for service users. EVIDENCE: Staff supervision is undertaken and recorded. Regular handovers ensure that all workers are aware of the service users needs. Service users are encouraged to help staff with light domestic chores in the home. A higher number of staff are on duty throughout the weekday period to provide for rehabilitation work, activities and health care visits. Staffing levels are reduced at weekends to minimum level were a more relaxed atmosphere prevails. However staff may use an on call system in an emergency. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 18 There is one waking night staff and one member of staff sleeping on the premises. The waking staff have been provided with a personal alarm to summon help if required for the protection of themselves or other service users. Examination of staff recruitment procedures found that a member of staff had commenced work without two satisfactory references. The manger reported they had followed Turning Point instructions on commencing the staff member’s employment. Showing the inspector an email of the instruction validated their comments. However the registered manger has overall responsibility for the protection of vulnerable adults when recruiting staff and must take this issue to senior mangers within the organisation. Staff training is provided in line with the service users needs, e.g. managing challenging behaviour and clinical risk assessment. Turning Point operates mandatory training in relation to staff induction and health and safety. The home is making good progress in staff undertaking NVQ promoting independence, however this number needs to be increased to 50 . Edward House DS0000005549.V271020.R01.S.doc Version 5.0 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 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): Service users and staff are encouraged to voice their opinions on developments in the home and felt their concerns were acknowledged. Record keeping needs to be maintained to promote the health and safety of service users. EVIDENCE: The manager is qualified RMN who has recently completed NVQ4 in management and has over 20 years experience in mental health issues. The home has good communication systems allowing the care needs of service users to be addressed. There was documented evidence that service users and staff had voiced their concerns on developments in the home. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 20 Minutes of service user meetings included discussions on key worker relationships, activities outside the home and if they were satisfied with meals and suppers. Service users were asked to arrange an agenda for the next meeting and take minutes. Evidence of staff meetings included matters of health and safety, clarification of policies and procedures and promoting choice for service users. Staff were also instructed to adhere to the planned menu and thanked for all their efforts over the Christmas period. Record keeping needs more attention in relation to medication, care planning and staff recruitment has mentioned previously in this report. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 21 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 3 X X X Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 X X 3 X 2 LIFESTYLES Standard No Score 11 3 12 2 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Edward House Score X 2 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X 2 X X DS0000005549.V271020.R01.S.doc Version 5.0 Page 22 Are there any outstanding requirements from the last inspection? No 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 YA20 Regulation 13(2) Timescale for action The registered person must 10/05/06 ensure that the medicines policy is developed and expanded to reflect current guidance issued by the Royal Pharmaceutical Society and comply with the National Minimum Standards. The registered person must 01/03/06 ensure that an accurate signed and dated record is maintained of all medication received and disposed off by the home. The registered person must 15/03/06 ensure that residents who wish to manage their own medication are assessed as to their ability to do so, before medication is provided to them. Medication provided to residents for use “on leave” must be provided in appropriately labelled containers. The registered person must 15/03/06 ensure that monitored dosage systems received Version 5.0 Page 23 Requirement 2 YA20 13(2) 17(1)(a) 3 YA20 13(2) 13(4)(c) 4 YA20 13(2) Edward House DS0000005549.V271020.R01.S.doc 5 YA20 13(2) 18(1)(c) 6 YA32 18 7 YA34 YA41 7/9/19 Schedule2 by the home are appropriately labelled with a description of medication contained. The registered person must 10/05/06 ensure that all staff members employed by the home, with responsibility for medication administration have received up to date appropriate training which includes an assessment of competency. The registered person must 30/06/06 ensure that the number of staff who has completed NVQ training is 50 . The registered person must 06/02/06 ensure that two written references are obtained for staff prior to commencement of employment. 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 YA19 YA41 Good Practice Recommendations The registered person should ensure the good progress in developing care plans is continued and that these include, signatures of the person completing them and dates of completion. The registered person should consult with service users on their preferred choice of holiday. The registered person should ensure that action is taken on all of the recommendations made by the pharmacist inspector. The registered person should ensure that the Commission of Social Care address and contact number is added to complaints leaflets when given to service users. DS0000005549.V271020.R01.S.doc Version 5.0 Page 24 2 3 4 YA12 YA20 YA22 Edward House 5 6 YA24 YA30 The registered person should ensure the homes refurbishment plan in completed in order to replace or recover bedroom chairs. The registered person should ensure that a review of the smoke extractors efficiency is undertaken for the health and welfare of service users. Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 25 Commission for Social Care Inspection Ashton-under-Lyne Area Office 2nd Floor, Heritage Wharf Portland Place Ashton-u-Lyne Lancs OL7 0QD 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. Extracts may not be used or reproduced without the express permission of CSCI Edward House DS0000005549.V271020.R01.S.doc Version 5.0 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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