CARE HOME ADULTS 18-65 Halifax Drive Care Home 72 Halifax Drive Leicester Leicestershire LE4 2DP
Lead Inspector Steve Hunnybun Unannounced 11 April 2005 9:30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Halifax Drive Care Home Version 1.10 Page 3 SERVICE INFORMATION
Name of service Halifax Drive Care Home Address 72 halifax Drive Leicester Leicestershire LE4 6DP 0116 234 0519 0116 234 0525 halifax.drive@craegmoor.co.uk Lansdowne Road Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Carol Watkins Care Home 34 Category(ies) of LD Learning disability (34) registration, with number of places Halifax Drive Care Home Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: None. Date of last inspection 21st October 2004 Brief Description of the Service: Halifax Drive Care Home is registered to provide care for thirty-four people with learning disabilities. The home provides group living and is divided into four units: Ash Lodge, Beech Lodge, Cedar Lodge and a bungalow located within the grounds, which provides more independent living for up to three people. There are 32 bedrooms in total of which 31 are single and one is double. one of the single rooms has an ensuite bathroom. The home is situated close to local amenities and within easy access of public transport links. Halifax Drive Care Home Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection took place over six hours and was the first statutory unannounced inspection for this year. Five case files were examined, and six residents spoke with the inspector. The manager and two staff also spoke with the inspector and care practice was observed. One service user showed the inspector her room. What the service does well: What has improved since the last inspection?
The last inspection was very positive with no requirements or recommendations. This time a number of recommendations have been made. This should not be seen as reflective of a general drop in the quality of care as it was evident that this remains high. The focus of inspections has changed to concentrate far more on outcomes for residents rather that simply on systems
Halifax Drive Care Home Version 1.10 Page 6 such as policies and procedures. All residents except one who spoke with the inspector were very positive about the home and the care they receive. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Halifax Drive Care Home Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Halifax Drive Care Home Version 1.10 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 & 5 While most residents needs have been assessed one has not and this could lead to her needs not being met. The fact that written contracts cannot be read by residents means that they are potentially unaware of their rights and responsibilities within the home. EVIDENCE: Files tracked contained assessments based on activities of daily living although one had no assessment and contained no reference to the resident’s boyfriend. In conversation with the resident it was clear that her relationship is important to her. The file furthermore contained no reference to the fact that the boyfriend has been excluded from the home. The resident’s daily record also contained very little reference to the boyfriend and no record of his exclusion. The same resident stated that she is not happy at the home. She stated that this is because other residents pick on her. The inspector explored this to determine that she does not feel picked on by staff and she reiterated that it is residents not staff who make her feel unhappy. The resident’s social worker is currently seeking alternative accommodation for her. Staff appear to be supporting her appropriately. Halifax Drive Care Home Version 1.10 Page 9 All files tracked contained contracts and documents outlining terms and conditions but these were not in a form that would be accessible to residents. Halifax Drive Care Home Version 1.10 Page 10 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9,10 While care plans were generally good there were specific examples where residents needs were not adequately reflected in their plans. The home’s staff are creative in enabling residents to make choices and decisions about their lives. From reading the files and talking to residents it was not clear that they are supported to take risks to enhance their independence. Information about residents is not well recorded and would make it very difficult for anyone to obtain information about the resident in order to inform future care planning. EVIDENCE: All files tracked contained care plans. These were generally good but one was incomplete. This contained no reference to the resident’s boyfriend; see evidence for standards 1-5. In three cases it became clear when reading daily
Halifax Drive Care Home Version 1.10 Page 11 records that challenging behaviour was an issue as records had been made relating to specific incidents. This was not reflected in the care plans. Care plans did contain useful information that would enable staff to support residents in making decisions and choices. The inspector spoke with several residents and they confirmed that they are able to make a range of choices including meals, décor of bedrooms and day care use. There were examples of risk assessment in files but these were limited. In some cases care plans contained references that could have been covered in risk assessments. There were no risk assessments relating to challenging behaviour. Daily records in files tracked were poor. They contained phrases such as ‘X was in a good mood or bad mood today’, without providing evidence of how that conclusion had been drawn such as observations of behaviour or demeanour. The file of the resident who has a boyfriend only mentioned him by his first name but contained very little other information about him. Halifax Drive Care Home Version 1.10 Page 12 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,15,16,17 The home’s staff support residents to access a range of day care activities. Residents are enabled to be part of the local community. There is inconsistency in the recording of resident’s relationships. This could lead to staff being unaware of a resident’s partner and the importance of the relationship. The home’s rules do not appear to restrict resident’s freedom of movement around the home. Residents enjoy their food and are offered a nutritious and varied diet. EVIDENCE: Files indicated a range of day care activities. One resident who spoke with the inspector had been to college on the day of the inspection. One file contained notes from a review of the resident’s day care provision in which efforts were being made to enable the resident to continue with day care.
Halifax Drive Care Home Version 1.10 Page 13 All files tracked contained reference to resident’s ability to access local community facilities. These included risk assessments for the use of public transport. While most files did contain references to family and friends in one file this was absent despite the fact that the resident is in a relationship, see evidence for standards 1-5. One resident who spoke with the inspector is married, although not living with her husband as a couple, they are able to maintain the relationship they do have. Files indicated that residents are able to move freely about the building. This was confirmed when the inspector spoke with and observed residents. Files contained references to service users dietary needs, likes and dislikes. All residents who spoke with the inspector stated that the food is good. One resident stated that she does not like the mushy peas but that she is always offered an alternative. Halifax Drive Care Home Version 1.10 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18,19 Residents personal and healthcare needs are generally met although there could be a little more detail in care plans about these. EVIDENCE: Resident’s personal and healthcare needs are recorded in their care plans although in some cases this could be in more detail. All residents are registered with a local GP and all appointments are recorded along with any advice or outcomes. Residents who spoke with the inspector stated that they receive appropriate care. Halifax Drive Care Home Version 1.10 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22,23 Residents are aware of how to air their views and concerns. The procedure ensures that complaints are taken seriously and acted upon. Policies and procedures contribute to keeping residents safe. EVIDENCE: The home has robust procedures for complaints and protection that are displayed throughout the building. All residents who spoke with the inspector stated that they know who to speak to should they have cause to complain. Complaints are recorded in a book; there was one example that had been resolved at the time it had been made. Halifax Drive Care Home Version 1.10 Page 16 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. They will be looked at during the next inspection later in the year. EVIDENCE: Halifax Drive Care Home Version 1.10 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. They will be looked at during the next inspection later in the year. EVIDENCE: Halifax Drive Care Home Version 1.10 Page 18 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) These standards were not assessed on this occasion. They will be looked at during the next inspection later in the year. EVIDENCE: Halifax Drive Care Home Version 1.10 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. 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x 2 Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 3 x 2 2
Score Standard No 24 25 26 27 28 29 30
STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x 3 3 x 2 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 Score 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x x x
Page 20 Halifax Drive Care Home Version 1.10 21 x Halifax Drive Care Home Version 1.10 Page 21 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. 1. Standard Regulation None. 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. 1. 2. 3. 4. 5. 6. Refer to Standard 2 5 6 9 10 15 Good Practice Recommendations It is recommended that all residents needs are assessed and that the assessement accuratley reflects their needs. It is recommended that all contracts between residents and the home are produced in a format that is accesible to people with learning disabilities. It is recommended that all care plans are reveiwed to ensure that they accuratley reflect residents assessed needs. It is recommended that risk assessments are reviewed to more accuratley reflect residents needs. It is recommended that daily records are recorded with observations and not vague assumptions about residents needs. It is recommended that details about residents personal relationships are always recorded accuratley in their files along with any important information relating to such relationships. Halifax Drive Care Home Version 1.10 Page 22 Commission for Social Care Inspection The Pavilions 5 Smith Way Enderby, Leicester Leicestershire, LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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