CARE HOME ADULTS 18-65
Halifax Drive Care Home 72 Halifax Drive Leicester Leicestershire LE4 2DP Lead Inspector
Mr Steve Hunnybun Unannounced Inspection 4th October 2005 11:15 Halifax Drive Care Home DS0000006418.V256641.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 Halifax Drive Care Home DS0000006418.V256641.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. Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Halifax Drive Care Home Address 72 Halifax Drive Leicester Leicestershire LE4 2DP 0116 234 0519 0116 234 0525 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) Lansdowne Road Limited Vacant Care Home 34 Category(ies) of Learning disability (34) registration, with number of places Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. No additional conditions of registration. Date of last inspection 11th April 2005 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 DS0000006418.V256641.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the second statutory inspection this year and took place over four hours and forty-five minutes. Three residents files were tracked, the manager, staff and residents spoke with the inspector. The manager also took the inspector on a tour of the building. This was generally a positive inspection with a number of the recommendations from last time now being met. Residents appeared happy and well looked after and one stated that he is happy at the home. Residents’ views are sought regarding the service given at the home. Other stakeholders are also surveyed. Generally the home is proactive in promoting health and safety. What the service does well: What has improved since the last inspection?
A resident mentioned in the last inspection now has information in her care plan and assessment regarding her relationship with her boyfriend. Care plans are generally improved since the last inspection. Risk assessments and daily recording have improved somewhat since the last inspection. Details of a particular residents’ relationship with her boyfriend are now in her care plan. Halifax Drive Care Home DS0000006418.V256641.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. Halifax Drive Care Home DS0000006418.V256641.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 Halifax Drive Care Home DS0000006418.V256641.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): 2,5 Not all residents’ have been assessed and this could lead to their 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: Of the three files tracked two contained assessment documents although these were not dated. The other file contained no assessment documents. One resident was identified at the last inspection because her care plan contained no reference to her relationship with her boyfriend. This has now been rectified. All files tracked continue to contain contracts between the home and the resident. These are still not in a form that is accessible to people with learning disabilities. Halifax Drive Care Home DS0000006418.V256641.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): 6,9,10 Residents’ needs are reflected in their care plans. A risk-assessed approach to enable independence is not applied consistently to all residents. The way information about residents is recorded would make it difficult to obtain information about the resident in order to inform future care planning. EVIDENCE: Files tracked contained care plans that contained information identified as missing at the last inspection. One file had no risk assessments, one only had one and the other had several that mainly related to moving and handling. Daily records continue to be written using vague, non-specific terms although this has improved since the last inspection. Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 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): 15 Residents are supported to maintain relationships. EVIDENCE: The care plan examined at the last inspection now contains information regarding the residents’ relationship with her boyfriend, including guidance on how she is to be supported to maintain that relationship. Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Residents are protected by the home’s medication policy. EVIDENCE: Medication processes were observed and it was clear that medication is stored, administered and recorded appropriately. Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 Page 12 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): 23 Residents are protected from abuse. EVIDENCE: The home has a robust adult protection procedure and staff have access to the Multi-Agency Vulnerable Adult Protection document No Secrets. Residents are asked to sign for any monies issued to them and where this is not possible two staff signatures are required. A robust checking system is in place for all money handled within the home. All staff receive training on adult protection issues. Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 Page 13 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): 24,30 The areas identified below are not conducive to a homely, comfortable and safe environment. The toilets identified below smelt strongly of damp and urine. EVIDENCE: The inspector toured the building and a number or areas of concern were identified: Ash Lodge; the shower is unsafe. There is a raised shower tray presenting a trip hazard and the electric shower presents a potential scalding hazard. The toilet is not accessible to people with a physical disability. Beech Lodge; the bathroom is inaccessible to people with a physical disability and is too small. The toilet is very small and the cistern is broken. Ventilation is poor in the toilet. The toilet within the laundry area is unsuitable. It is inaccessible and small. Cedar Lodge; the shower room is too small and would not allow access for a resident and a carer. The toilet is poorly ventilated, small and the flooring is stained. The downstairs toilet is unacceptable. It is very small, dark and poorly ventilated. The downstairs bathroom is in need of refurbishment; damp has penetrated the wall through to the corridor outside.
Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 Page 14 All the above areas need refurbishing to ensure that the facilities are suitable for the residents. Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 Page 15 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): 34,35 Residents are protected by the home’s recruitment policy. Staff are trained to provide them with the necessary skills to meet residents’ needs. EVIDENCE: Recruitment is carried out under the company’s central procedures, which are comprehensive and robust. All new recruits are required to supply two references and a clear CRB check before starting work. All staff undertake a comprehensive training programme. Most have appropriate NVQ awards. The inspector was shown an example of an annual development plan that all staff have. This is a record of all training, supervision and appraisal throughout the year. Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 Page 16 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): 39,42 Residents’ views and those of their relatives are sought regarding the service provided. Residents’ health and safety are promoted, although a malfunctioning fire alarm system would not be spotted, as it has not been tested recently. EVIDENCE: There is a system in place to seek the views of residents and stakeholders regarding the service. The manager stated that questionnaires are due to be sent out shortly. The home has a comprehensive fire risk assessment. Fire drills and tests of the alarm system are carried out regularly although only one drill has been carried out this year and the alarm has not been tested for some weeks. The home has a water risk assessment that covers areas such as water temperatures and leigionella. Generic risk assessments have also been completed for other hazards within the building. Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 Page 17 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 2 X X 2 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 2 Standard No 24 25 26 27 28 29 30
STAFFING Score 1 X X X X X 1 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Halifax Drive Care Home Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000006418.V256641.R01.S.doc Version 5.0 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA24 Regulation 13 Requirement The provider is required to produce an action plan, including timescales and costings, detailing how the areas outlined are to be improved. A copy to be submitted to the commission. Timescale for action 31/10/05 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. Refer to Standard YA2 YA5 Good Practice Recommendations It is recommended that all residents’ are assessed and that the assessment accurately reflects their needs. (partly met from the last inspection). It is recommended that all contracts between residents and the home be produced in a format that is accessible to people with learning disabilities. (Unmet from last inspection). It is recommended that risk assessments be reviewed to ensure they more accurately reflect residents’ needs. (Partly met from last inspection). It is recommended that daily records be completed with observations and not vague assumptions about residents needs. (Partly met from last inspection).
DS0000006418.V256641.R01.S.doc Version 5.0 Page 19 3. 4. YA9 YA10 Halifax Drive Care Home 5. YA42 It is recommended that regular fire system tests and fire drills be carried out. Halifax Drive Care Home DS0000006418.V256641.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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