Inspection on 22/12/05 for Halcyon House

This inspection was carried out on 22nd December 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Halcyon House 14/05/08

Halcyon House 17/05/06

Halcyon House 24/05/05

Halcyon House 02/11/04

Halcyon House 11/05/04

Similar services:

2 Perhaver Park

The Vicarage

St George`s

5 Seafield Road

Credence House

Radfords

Honeybourne House

32 Beaumont Way

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

CARE HOME ADULTS 18-65 Halcyon House Halcyon Road North Prospect Plymouth Devon PL2 2PJ Lead Inspector Brendan Hannon Unannounced Inspection 22nd December 2005 1:30 Halcyon House DS0000003530.V274179.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 Halcyon House DS0000003530.V274179.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. Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Halcyon House Address Halcyon Road North Prospect Plymouth Devon PL2 2PJ 01752 605541 NO FAX 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) H4037@mencap.org.uk Royal Mencap Society Mrs Linda Jean Lewin-Smith Care Home 9 Category(ies) of Learning disability (9), Physical disability (9) registration, with number of places Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th May 2005 Brief Description of the Service: The home is located in a single storey purpose built detached building within a row of ordinary semi detached houses in the North Prospect area of central Plymouth. A full range of amenities and facilities are within walking distance though, the home has its own vehicles and the central shopping area of Plymouth is accessible by public transport. The home can accommodate up to nine residents. The home is fully accessible to residents and visitors who use wheelchairs. The home has one main entrance from which all parts of the home may be accessed. The communal areas of the home are in one half of the building and the residents’ bedroom accommodation is in the other half. There are two communal bathrooms and two communal showers. There is one double bedroom. There are two communal areas in the home. A lounge and dining area and another lounge accessed from the lounge/ diner. There is a medium sized area of garden and patio to the rear of the building and this is fully accessible to the residents. This area can be accessed either round the side of or from the rear of the building. The service offered by the home is for men and women with a learning disability between the ages of 18 and 65. Some of the residents have substantial mobility needs. The present group of residents are of a mixed range of ages and abilities but are in the main very active within the home and in the community. Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced. Preparation for the inspection included analysis of the annual pre inspection questionnaire, the previous inspection report and contacts with the home over the last 7 months. An inspection plan was developed from this information. The inspector was in the home from 1.30pm to 4.30pm. The inspector spent time with or spoke to the three of the nine residents present during the inspection. The whole of the building was inspected. The four staff in the building were spoken to during the inspection. Medication records, general records, health and safety records, and staffing rotas were inspected. What the service does well: The home has a stable staff team. The management and staff aim to provide a homely and comfortable place for the residents to live. The home provides good information about the service to potential new residents, and their representatives, so that they can make an informed choice about whether to use the service. The service states clearly the needs that it can meet. The planning and delivery of resident’s care is good. There is an individually planned scheme of appropriate activity for each resident that ensures that all the residents enjoy a good quality of life both through leisure and valued life activity, such as education courses. Residents’ personal care needs are well met by an effective staff team. The system of medication administration in the home is managed effectively. Complaints are investigated appropriately using the complaints procedure and policy. The home was commended on the accessible complaints procedure that has been implemented by the home and the organisation and for thorough actions taken in response to complaints. The residents benefit from a homely, comfortable, clean and adequately maintained building that has been appropriately adapted to meet their needs. Resident’s needs are well met by enough competent, trained and vetted staff. Thorough personnel checks help to protect the vulnerable adults who live in the home. Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 6 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. Halcyon House DS0000003530.V274179.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 Halcyon House DS0000003530.V274179.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): 1,3 The home provides adequate information about the service to allow a potential new resident, and their representatives, to be assured that the service could meet their needs. EVIDENCE: Both the service users guide and the homes statement of purpose were available. The information in these documents would enable potential new residents and their supporters to understand the service provided by the home and to make an informed decision as to whether to use the service. Residents and care staff were observed and spoken to throughout the inspection. Through this observation, inspection of care plans, and through records there was good evidence to show that residents needs are being met. No residents have moved out of or into the home for some time. However there is a pre admission assessment form and procedure available to use before a new resident is admitted to the home should the need arise in the future. This process would ensure that no new service user is admitted whose needs could not be met by the service. Halcyon House DS0000003530.V274179.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): 6,7,8 Good care planning and risk assessment of residents needs is being maintained by the home. EVIDENCE: Resident’s care plans are of good quality enabling the delivery of consistent and considered support to the residents. All the residents’ had a care plan and risk assessments in place. The registered manager was advised to bring the care plan and risk assessment elements together to make all the information more easily accessible. The personal planning file has a list of the regular activities participated in by the resident. The home is introducing a new photographic care plan in order to make the information held in the care plan more accessible to each resident. At present the information in four of the nine resident care plans has been put into this new photo based format. Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 10 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): 12,13,17 Residents have enough appropriate activity to ensure a good quality of life while living at the home. EVIDENCE: The staff on duty described the activities that were taking place over the Christmas period. A number of residents were being supported to go to the Panto at the Theatre Royal in Plymouth and various other Christmas events were being to be attended by the residents. Despite some short term staffing difficulties the staff were seen adapting swiftly to manage the residents transport and escort needs to ensure that all the residents enjoyed their planned activities outside the home. Daily records for each resident cover all the positive and negative elements of the resident’s day and provided clear evidence of the quality of life enjoyed by the residents. Each resident has a completely individualised activity plan both for activities within the home and in the community, enabling the planning of a full lifestyle for each resident. Some regular activities participated in by residents outside the home include horse riding, music workshops, adult education and swimming. Within the home karaoke, bingo, and individualised arts and crafts, are enabled by the staff. Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 11 Halcyon House DS0000003530.V274179.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): 18,20 The welfare of the residents is maintained by meeting the residents’ personal care needs. EVIDENCE: All the residents present in the home at the time of the inspection were seen. There was good observable evidence that complex personal care needs are being met. Efforts had been made throughout the home to minimise any potential institutional atmosphere by making the building homely wherever possible. The observed delivery of personal care showed that the service is caring and professional in the way in which personal care support is provided to the residents. The home uses a monitored dosage system of medication administration. The record and storage of this system was well maintained. The health of the residents is supported by the effective administration of their medication. Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 13 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 Complaints are properly managed by the home, which protects the welfare of the residents. EVIDENCE: There is a good accessible complaints procedure and this is clearly displayed in the home. The complaints procedure uses pre paid and addressed postcards. These postcards are made freely available and if used would go directly to the MENCAP organisation outside the home. This method would help support a resident to feel free to raise a concern and to ensure that any complaint would be investigated objectively from outside the home. There has been one complaint made by one resident towards another since the last inspection. This issue is presently being investigated but any risks have been assessed and the situation is considered safe. The home and organisation are commended in this report for their support for residents to raise any problems they may experience and then to have these resolved by the organisation and the home. All care staff receive anti abuse training as a standard training element early in their career at the home. The home has all the appropriate anti abuse policies and procedures in place. Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 14 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): 24,26,27,28,29,30 The residents benefit from a homely, comfortable, clean and well maintained building that has been appropriately designed to meet their needs. EVIDENCE: The home was looked at closely and only some limited damage to doors and skirting boards, due to wheelchair use, was noted. The home is well maintained. There is a good quality of living environment and a good level of decoration in the home. The kitchen has been redecorated since the last inspection. The home was clean and hygienic. The residents benefit from a personalised, clean and well maintained building to live in. The home was originally designed to meet the needs of people with significant mobility needs. Each bedroom has been decorated and personalised to meet the taste of the resident using it. There are accessible toilets available throughout the home. All toilets and bathroom doors have been fitted with locks that can be overridden from the outside in the event of an emergency. This facility protects both the privacy and the safety of the residents. All hot water outlets have been fitted with water temperature control valves. Most radiators available to residents have been covered or a risk assessment is in place to demonstrate that a cover is not necessary at this time. These measures protect residents from the danger of scalds and burns. Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 15 All the residents have been offered the use of an individual lock on their bedroom door. The availability of locks supports residents independence and privacy. Some of the residents have chosen to use a key to their bedroom. Others have chosen not to use a key or risk assessment has clearly shown that holding a key would create an unreasonable risk. Halcyon House DS0000003530.V274179.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): 33,34, Resident’s needs are met by enough competent properly vetted staff. EVIDENCE: Discussion with the senior staff on duty, together with inspection of the staffing rota plan showed that the residents’ needs would be met by appropriate staffing levels over the Christmas period. The home has a minimum of three care staff on each morning and evening. Personnel records were available in the home to verify the recruitment procedure carried out for each member of staff. Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 17 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): 39,41,42 The management of the home is effective which ensures that good quality care is consistently delivered to meet the residents’ needs. EVIDENCE: The Registered Manager, Linda Lewin-Smith, became manager at the home in 1992. She has obtained qualifications equivalent to NVQ4 in care and the Registered Managers Award. The staff were seen to be working well together without a member of the management team being on duty during the inspection. Good working relationships amongst the staff will promote better quality support for the residents. The organisation has developed a quality assurance system that is focussed on residents concerns. The system is based on questionnaires and therefore some residents will need help to fill these out. However such difficulties should not stop the residents engaging in this process, which is designed to improve the quality of their service. Health and Safety is well managed in the home. Comprehensive safety checks have been carried out during the last year, as noted in the annual pre inspection questionnaire, including gas appliances, Legionella and electrical Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 18 equipment. Good management of health and safety protects the welfare of the residents. Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 19 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 3 2 X 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 3 X 3 3 3 X 3 3 X Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 20 No 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Halcyon House DS0000003530.V274179.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Ashburton Office Unit D1 Linhay Business Park Ashburton TQ13 7UP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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