Inspection on 09/11/06 for Haisthorpe House

This inspection was carried out on 9th November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Haisthorpe House 22/07/08

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Haisthorpe House 139 Holgate Road York YO24 4DF Lead Inspector David White Key Unannounced Inspection 9th November 2006 09:00 Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 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 Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 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 Older People and 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. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Haisthorpe House Address 139 Holgate Road York YO24 4DF 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) 01904 654638 01904 674000 Haisthorpe House Care Ltd Miss Sally Anne Plant Care Home 27 Category(ies) of Learning disability (27), Learning disability over registration, with number 65 years of age (27), Mental disorder, excluding of places learning disability or dementia (27), Mental Disorder, excluding learning disability or dementia - over 65 years of age (27) Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 27 (LD), up to 27 (MD), up to 27 (LD(E)) and up to 27 (MD(E)) up to a maximum of 27 users. Date of last inspection Brief Description of the Service: Haisthorpe House is a care home providing personal care and accommodation for 27 adults with mental illness and/or a learning disability. Haisthorpe House Care Ltd took over the ownership of the home in December 2005. The home is situated on Holgate Road close to the centre of York and is easily accessible to its facilities and amenities. The accommodation is of both single and double rooms over two floors and has single accommodation in selfcontained flats. There is a garden to the rear of the house and private parking for visitors. The current weekly fees at the time of the site visit ranged from £340 to £370 per week and did not include costs for hairdressing, private chiropody, toiletries and newspapers. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first visit to the home since Haisthorpe House Care Ltd had taken over its ownership in December 2005. This report follows an unannounced site visit undertaken on the 9th November 2006. This visit was carried out by one Regulation Inspector and took 7 hours with 4 hours preparation time. The home was able to return the requested information before this site visit. Information was used from the Regulation Inspector’s inspection record, which detailed the history of the home and relevant information about what had been happening in the home since Haisthorpe House Ltd had become the registered provider. The site visit comprised of an inspection of the premises. The care records of three clients were looked at which included clients assessments, care plans and medication records. Staff rotas, the home’s policy and procedures and health and safety documentation were inspected. Time was spent talking to four clients, a visitor to the home, three members of care staff, the cook and the manager. The activity in the home and the interaction between clients and staff was observed. The focus of the inspection was on a number of key standards and inspecting the case records of a number of clients to establish whether they corresponded with their experiences of life in the home. The manager was available throughout the inspection and the findings were discussed at the end of the inspection. What the service does well: Proper pre-admission procedures were being followed to ensure that prospective clients were only admitted to the home if their needs could be met. Clients were encouraged to make their own decisions and this helped with their independence. Clients were involved in the local community and had access to day care and educational facilities. A visitor said he was always made to feel welcome by the staff team and this encouraged his involvement in the home. Clients were complimentary about the quality; quantity and choice of food on offer at mealtimes and felt that their nutritional needs were well met. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 6 The home had a good atmosphere and clients felt staff were “helpful and supportive”. The staff team at the home were committed towards enhancing the quality of lives of the clients in the home and acted in their best interests. What has improved since the last inspection? 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. The summary of this inspection report can be made available in other formats on request. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Prospective clients received a range of information before moving into the home to help them with their decision-making and detailed information had been obtained about the prospective client by the home before admission to ensure they were able to meet the person’s needs. EVIDENCE: The home had updated its statement of purpose and service user guide to reflect the changes in the ownership of the home. Each existing and prospective client was given a copy of both documents that provided information about the aims of the home and the services and facilities on offer. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 9 The manager or her deputy carried out the pre-admission assessments of prospective clients and information from other sources such as GPs and social services are obtained prior to the admission of a client. An assessment of the prospective clients individual needs was carried out by the home as part of the assessment process. The clients care records contained a detailed baseline assessment of their needs from which a care plan was developed. The assessments were carried out with the involvement of the client and external professionals and it was clearly recorded when clients had chosen not to be actively involved in this process. A client who was one of the most recent admissions to the home said that he had visited the home “on a number of occasions” before deciding to move there. Each client had a contract explaining the terms and conditions of living at the home so that they were aware of their rights and entitlements. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Clients were encouraged to make their own choices where possible and good care planning systems were in place to provide staff with the information to meet the individual needs of each client. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 11 EVIDENCE: Three clients’ care records were looked at and these provided a range of information about each person. One section of the records was about the person’s life story and likes and dislikes. The client care plans covered each individual’s health; personal and social care needs and stated how these were to be met. Daily records were up to date and included input from other healthcare professionals and services. It was noted that in some cases the care plan reviews were due for some clients and had not been arranged and the manager was addressing this. Clients felt that they were encouraged to make their own choices and said that staff provided assistance when needed. The home operated a key worker system that enabled staff to spend time with clients on a one to one basis. A number of risk assessments had been undertaken in relation to aspects of daily living so that clients’ independence was promoted in a safe manner and any restrictions for the client were clearly recorded. Risk assessments were carried out with the involvement of the client and where appropriate external professionals. Some of the clients were considered a risk from harming themselves and the risk assessments set out actions to minimise potential harm to the client. One client had on occasions exhibited threatening behaviour towards others and the care plan detailed how this behaviour was to be managed to reduce the risks to the clients and others. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 13 12, 13, 15, 16 and 17 Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Clients enjoyed a range of activities and were able to access the local community facilities. EVIDENCE: Client care plans included information about the person’s life history and this included their social interests. Whilst some of the clients preferred to spend most of their time around the home others were more involved in the local community. A number of clients attended a day care centre where they did gardening and others visited a local charity run organisation and enjoyed activities such as computer group sessions and some clients had involvement with the church. One client had attended a poetry and English course run at a local school and another had completed an art course at York College. The home carried out their own activities such as bingo and quizzes and organised trips out to the local pubs and theatres. Some of the clients had enjoyed a seaside holiday earlier on in the year. Clients contributed towards a social fund that was used to help with the costs of trips out. Clients said that they were willing to do this and those who did not wish to contribute were able to do so. Clients said that they generally got on well together most of the time and this was observed at the time of the site visit. One client was receiving a visit from a member of a befriending service who said that he was “always made to feel welcome” when visiting the home. Visiting arrangements were flexible and clients could see family and friends whenever they wanted to do so and there was a telephone in the home if clients wished to communicate via this manner. Clients said that they were able to choose their own daily routines. One client liked to stay in bed until mid morning and was able to do so. All the clients were given a choice of whether they would like a front door key and risk assessments were carried out to support any decisions made and clients had keys to their bedrooms. Staff were observed to be treating clients in a respectful manner and addressed them by their preferred names. Clients commented that staff always knocked on their bedroom doors before entering and this was observed during the site visit. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 14 The home employs two cooks to help in meeting the nutritional needs of the clients. Clients said that the quality of the food was “good” and one commented “we can have second helpings if we want”. Alternative meals were available if clients did not like the food options and extra foods were bought in advance for this purpose. All the staff had attended some food hygiene training and weight records were maintained so that any issues around weight gain or loss could be addressed. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Clients received personal support in accordance with their wishes and had access to specialist services when required to ensure that their healthcare needs were met. EVIDENCE: Clients felt that the care they received was “good” and that staff were “approachable, kind and friendly”. One client described the home as “a good place to live”. Although some clients needed little in the way of personal Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 16 support, those needing assistance felt that this was given in the way they preferred. Each client had a GP and access to dental, optical and chiropody services when needed. A number of clients also received support from mental health services. Within the care records there was evidence that client medications were regularly reviewed and the outcomes from the reviews were clearly recorded. The home’s medication system and facilities were inspected and found to be satisfactory. The Medication Administration Records (MAR) were accurate and up to date and weekly audits were carried out to monitor medication procedures. The medicine cupboard was located in the kitchen area and this was discussed with the manager who will be seeking advice from the supplying pharmacist in this matter in order to ensure safe medication practices. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. A complaints policy and procedure was in place to address any concerns. The home’s policy and procedure did not reflect external guidance on how to deal with abuse, however despite this staff had a good understanding of how to respond to abuse. EVIDENCE: The home had a complaints policy and procedure that detailed how complaints would be dealt with within given timescales. Clients and a visitor all knew whom they needed to speak to if they had any concerns and were confident that concerns would be dealt with properly by the management of the home. The home their own policy and procedures for safeguarding people from abuse and had a copy of the City of York’s Multi-Agency Adult Protection Policy and Procedure. However, the home’s own policy and procedure did not reflect those Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 18 of the local multi-agency and provided misleading information on what to do if abuse had occurred or was suspected and therefore did not safeguard clients from potential risk of harm. Despite this those staff spoken to had a good understanding of what would constitute abuse and the actions needed to be taken and staff had received some abuse awareness training. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. Quality in this outcome area was adequate. This judgement has been made using available evidence including a visit to this service. The environment was comfortable and safe for clients although further refurbishment work was needed to improve the living conditions for the clients. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 20 EVIDENCE: Accommodation was situated over two floors in the main part of the building and could only be accessed via stairs so would not be suitable for people with mobility problems if there were no vacant bedrooms on the ground floor. The home did have ramped access so that people with a mobility problem could have access to and from the house. There were also four self-contained flats in the grounds of the home and these had en-suite facilities. The bedrooms in the main part of the building were personalised and although they did not have ensuite facilities there was easy access to bathroom and toilet areas and the home had a portable bath seat to assist people with mobility problems to have a bath. Clients said that they liked their bedrooms although one mentioned that she had experienced difficulty sleeping at night on occasions when the security lights near to her bedroom had been activated at night causing too much brightness and it was recommended that actions were taken to rectify this problem. The home was undergoing some refurbishment work and as part of the refurbishment programme a downstairs corridor and some of the bedrooms had been decorated and this had improved the standard of the environment. However, a lot more work was needed to other parts of the building and the manager commented that she had recently met with the proprietors of the home and action was planned to address this matter. Clients were encouraged to maintain their own bedrooms with the support of staff and a cleaner was employed to maintain the cleanliness of the home. It was noted in the bathroom areas that the extraction fans were dusty and in need of cleaning and this was addressed at the time of the site visit. The kitchen was clean and proper procedures were being followed to promote safe food hygiene practices. The home had separate laundry facilities to attend to client’s personal clothing. A fire risk assessment had been carried out by the home and following consultation with the local fire safety officer actions were being taken to address issues from this. Fire safety equipment tests and maintenance records were up to date and recommendations made from a recent environmental health authority visit had been acted upon. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 and 35. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. Clients received a good standard of care from a well-motivated and enthusiastic staff team, however one aspect of the recruitment procedures needed to be improved to ensure that residents were safeguarded from potential harm. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 22 EVIDENCE: Staff were given a job description when they started working at the home and discussion with members of the staff team indicated that they were well aware of their roles and responsibilities. Staffing levels were sufficient in ensuring that client needs could be met and additional staffing hours were being given to clients who required extra support. Clients and staff all felt said that the staffing levels were “good” and staff could be observed to be providing support and care in an unhurried manner and clients said that they were always able to access a staff member if they needed to. Sufficient staffing levels meant staff were able to spend time with clients on an individual basis and were able to carry out some activities within the home. Both staff and clients felt that the care at the home was good and a member of staff commented that the home was a “good place” to work. There was a friendly atmosphere around the home and staff morale was good. Staff received a range of training to equip them in meeting the needs of the clients and some of the staff team had attended some mental health foundation training to give them a better understanding of the specific needs of the client group at the home. However, not all staff had received any training specific to the needs of people with a mental health problem or a learning disability and it was recommended that this should be arranged. Most of the staff had either completed or were undergoing the National Vocational Qualification (NVQ) programme to enhance their skills and knowledge. An induction programme was in place for all new staff and this was detailed and covered a number of aspects of working at the home. The staff files were looked at and it was noted that all the necessary preemployment checks had been carried out. However in the case of a recently appointed care worker whilst a POVA first and Criminal Record Bureau check had been requested the care worker had commenced work prior to the completion of these checks. This practice needed to be addressed to safeguard clients from possible harm. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 24 37, 39 and 42. Quality in this outcome area was good. This judgement has been made using available evidence including a visit to this service. The home was well run in the best interests of the clients and overall proper attention was given to ensuring their health and safety. EVIDENCE: The manager was very experienced in running the home and was about to complete the Registered Manager’s Award. A deputy manager was in post to support the manager in providing leadership to the home. Both the clients and staff described the manager as “supportive and helpful”. The home had developed some systems for seeking the views of others about the home. Clients were asked to complete a questionnaire to enable them to provide their views about the care and services on offer. Monthly house meetings were also held and recorded and clients said they were encouraged to give their opinions about the home. Regular staff meetings also took place and staff said they felt they could contribute towards these and that their views would be listened to and supervision systems were in place so that management were aware of any staffing issues. At the present time there were no formal arrangements in place to seek the views of relatives or healthcare professionals who had contact with the home and it was recommended that this should be organised. A representative from Haisthorpe House Ltd carries out an unannounced monthly visit to the home to monitor and look at ways of improving the care and services at the home and a report was made of their findings. Arrangements were in place for the promotion of a safe and secure environment for clients, visitors and staff. A number of satisfactory certificates and reports were seen relating to the premises. All staff had received health and safety training and accidents were clearly recorded within the home’s accident records to protect the interests of clients. In order to promote the safety of the clients proper pre-employment checks needed to be carried out before new staff started work at the home and staff needed to be given clearer guidance through the home’s policies and procedures about dealing with abuse. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 25 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. Where there is no score against a standard it has not been looked at during this inspection. 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 3 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT Standard No Score 37 3 38 X 39 2 40 X 41 X 42 3 43 X 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Haisthorpe House Score 3 3 3 X DS0000064101.V316476.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? N/A 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 YA23 Regulation 13 Requirement The registered person must make arrangements to ensure that all staff are given clear guidance on local authority procedures for reporting abuse issues. Timescale for action 09/12/06 2 YA34 19 The registered person must ensure that staff are not deployed at the home until confirmation is received that they have had as a minimum requirement an up to date Protection of Vulnerable Adults check. 09/11/06 Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 27 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 2 3 4 5 6 7 Refer to Standard YA6 YA20 YA24 YA24 YA35 YA37 YA39 Good Practice Recommendations Care plan reviews should take place on a more regular basis. The registered person should seek advice from the supplying pharmacist in relation to the medicine cupboard being located in the kitchen. The registered person should make arrangements to make sure that clients sleep patterns are not affected by the activation of the security light system. The home should continue to implement its refurbishment programme in order to improve the standard of the decoration and furnishings within the premises. All the staff should receive training specific to the needs of people with mental health problems and/or a learning disability. The registered manager should complete NVQ level 4 in order to maintain and enhance her management skills. The quality assurance system should be developed further to seek the views of relatives and others who have contact with the home in order to improve care and services in the home. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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. Haisthorpe House DS0000064101.V316476.R01.S.doc Version 5.2 Page 29 - 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. 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