Inspection on 06/07/05 for Handsworth Development

This inspection was carried out on 6th July 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 14 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Handsworth Development 11/06/07

Handsworth Development 24/02/06

Handsworth Development 02/11/04

Handsworth Development 14/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Handsworth Development 63-65 St Josephs Road Handsworth Sheffield S13 9AU Lead Inspector Claire McAuley Unannounced 6 July 2005 09:30 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. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Handsworth Development Address 63-65 St Josephs Road Handsworth Sheffield S13 9AU 0114 254 8291 0114 269 0381 None Northern Counties Housing Association 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) Ms Diane Margaret Bentley PC Care home only 12 Category(ies) of LD Learning Disability (12) registration, with number of places Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. This registration includes 8 places for people with an additional physical disability (PD). This registration also includes 8 places at 101, 103, 105, 107 Hall Road, Sheffield S13 9AH. One specific service user, named on the application to vary registration form dated 15/07/03 who is over the age of 65 can reside at the home. Date of last inspection 2 November 2004 Brief Description of the Service: Handsworth Development provides a service for 12 adults with learning and physical disabilities. Four people live at one bungalow, and two people live in each of the four adjoining bungalows nearby. The bungalows are all purpose built, and are situated in the Handsworth residential area of Sheffield which has good access to public transport and shops. The bungalows are all easily accessible to wheelchair users, have single bedrooms and large landscaped gardens. Each bungalow has a car parking area. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over five hours from 9.30 14.30. Previous requirements were checked and a number of key standards assessed. Areas of all the bungalows were inspected. Three residents were able to express an opinion on the quality of care offered to them, and three members of staff were also asked their opinions. A number of records were checked and discussions took place with the team leader and administrator. What the service does well: What has improved since the last inspection? What they could do better: A system of ascertaining service users and their relatives/representatives views on the service should be developed, and further consultation with relatives, in the form of meetings should be introduced. Further work on leisure needs is required, to enable residents to go out more and access more community activities. A recruitment file checked did not contain the full range of required information. To protect residents, supervision of staff should be carried out at the required level of six times per year, and training for staff in adult protection, and mandatory training should be fully completed. Advocates for residents should be made available. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 6 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. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 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 Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 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) 1 2 5 There was an appropriate statement of purpose/service users guide in place. Residents were not admitted to the home without a full needs assessment being undertaken. Each resident had a written contract in place. Some required signing. EVIDENCE: The statement of purpose/service users guide contained all of the required information. In order to aid the understanding of those with learning disabilities, some parts were in pictorial format, and it was also produced in video form. A copy of the statement of purpose/service user guide was available for all those who wanted to see it. The team leader confirmed that all residents admitted to the home in recent years had a full needs assessment in place prior to their admission. A service user contract was in place that met the standards and was produced in pictorial format. Not all contracts were signed by the resident or their representative. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 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 standard(s) 6 7 8 9 Care plans were of a high standard and addressed all the needs of the residents and action staff should take. Residents were encouraged to make decisions about their own lives. Risk assessments identified where residents needed assistance to maintain their health and safety. EVIDENCE: Care plans seen were of a high standard and covered all of the required information. They were based on person centred planning principles. A key worker system was in place. The plans were regularly reviewed and updated. Residents were involved in making decisions about their own lives. One resident spoken to described his week, and was happy about attending Gateway Club and a work placement. Service users were not able to manage their own finances due to their learning disabilities. No advocates were accessed by the home for residents, generally, relatives acted as advocates. Residents were involved in the running of the home as much as possible, including shopping and choice of food. One resident had recently been involved in the recruitment of staff. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 10 Individual risk assessments were seen on plans of care, these included travel, and moving and handling risk assessments. Action was taken to minimise risk while supporting residents to take considered risks. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 13 14 15 17 Residents were supported to attend day placements where appropriate. Their spiritual and emotional needs were met. Residents were able to participate in the local community, and arrange suitable holidays. Staff felt that residents did not go out enough. Appropriate activities were provided, and family links and friendships were maintained. Menus were chosen by residents and were well balanced. Special dietary needs were detailed. EVIDENCE: There were two residents who attended day placements, however, due to illness; one placement was suspended at present. The other residents did not have day placements, as those available did not meet their needs. Staff undertook a continuous process of assessing and providing suitable activities including fulfilling spiritual needs for residents. Residents were able to participate in the local community and staff supported them in outings to local pubs and shops. Residents were involved in choosing where they wanted to go. The home had a minibus, however, staff spoken to felt that residents did not go out often enough. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 12 A range of preferred activities was recorded on residents individual plans of care; these included listening to music, snoozelum, games and videos. All residents had the option of a seven-day holiday, and they were involved with the planning of this. Several holidays had been arranged over the summer, including a holiday to Ireland. Staff accompanied and supported residents on holidays. Staff confirmed that residents were supported to maintain family links and friendships inside and out of the home, as appropriate to their individual needs. The majority of residents had visits from relatives, and staff indicated that they had a good relationship with resident’s family members. Residents could choose what they wanted to eat. Two residents said they enjoyed their meals, and they could help to shop for food. Staff prepared food and involved residents where possible. Staff said that fresh fruit and vegetables were always offered to residents. Care plans showed details of likes and dislikes and there was a record of food provided. Special needs in relation to individual dietary needs and equipment was recorded. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 19 20 21 Staff provided a high standard of care, and had a good awareness of individual needs and were able to interact and communication with residents. Resident’s healthcare needs were met and individual specialised healthcare services and equipment was provided. Reviews and recording of health needs and information was in place. Appropriate medication systems were in place. Information on resident’s wishes in relation to growing old, terminal care and funeral arrangements was recorded. EVIDENCE: Staff spoken to demonstrated that they had a good awareness of how to maintain each resident’s privacy and dignity and were familiar with their particular needs. Interaction with residents observed was positive and gentle and it was clear that individual communication methods had been developed between each resident and staff members. Residents were guided in relation to their personal hygiene needs, and routines were flexible. Residents had individual technical aids necessary to maintain as much independence as possible, including overhead tracking in one bedroom. A key worker system was in place. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 14 Resident’s healthcare needs were met. Individual health needs were continually assessed and monitoring systems were in place. Detailed information on residents medical histories had recently been established, and also a folder to give to medical professionals when attending hospital had been developed. There was evidence on plans of care that residents had access to specialised services including speech therapists, occupational therapist, and chiropodists. Residents were unable to administer their own medication. Appropriate records were maintained of all medication received administered and disposed of. Medication training was in place and additional training from Lloyds pharmacy had been put in place. All staff were due to complete this. Medication was securely stored and the medication records of two residents checked were correct. Details of side effects were in place and medication reviews for residents had been recorded on plans of care. Plans of care recorded residents wishes regarding terminal care and funeral arrangements, and an agreement regarding residents wishes to stay at the home when they grow old was included. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 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 There was an appropriate complaints procedure and an adult protection policy and procedure in place. The majority of staff had received training on adult protection. The home had not received any complaints. EVIDENCE: There was a complaints procedure in place that contained the required information. This had been produced in a pictorial form for residents. There had been no complaints in the last twelve months. There was an Adult Protection policy and procedure in place and also the DOH Guidance (No Secrets). The majority of staff had received training on Adult Protection. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 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) 24 27 The home was generally comfortable, clean, safe, accessible, and furnished and decorated to a good standard. The outside areas of the home were pleasant and well maintained. Resident’s rooms were individually personalised. Bathrooms had appropriate equipment, but were clinical in appearance. EVIDENCE: The home consists of four adjoining bungalows and another bungalow nearby. All areas of the home were clean and smelled fresh. All areas of the home were accessible to wheelchair users, and furnishing and fittings were of a good standard. There was a maintenance and renewal programme. The outside garden areas were well maintained and accessible, and staff indicated that they had plans to make an outside sensory garden area soon. Some lounges at the home had stained carpets, and a washing machine, tumble dryer and cooker were awaiting repair. Resident’s rooms were individualised and comfortable. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 17 Bathrooms seen were appropriate to the needs of the residents, with specialised baths and equipment. There were a sufficient number of toilets. One bathroom had a bath panel which was damaged and the floor was marked by a metal cabinet. The bathrooms were clinical in appearance. The team leader said that they were due for redecoration soon under the maintenance programme. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 18 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) 33 34 35 36 For the safety of service users, staffing levels consistently met the required levels. Staff recruitment files contained the majority of required information, and CRB checks had been undertaken. Staff had induction and foundation training. but not Learning Disabilities Award Framework training. The level of staff supervision did not meet requirements. EVIDENCE: Staffing rotas were checked, for a two month period, and staffing numbers met the required level. Staff members said there were sufficient staff to meet the needs of the residents, and that all shifts were covered. Two regular bank staff were used, who were well known by the residents. The team leader said that extra staff could be brought in if particular events were planned with residents. He also said that at night, there was an on call manager, and other staff were willing to come in to the home to cover if an emergency occurred. Staff recruitment files were checked and they contained the majority of the required information. One file contained only one reference. The manager had completed a record to show that CRB checks were complete for all staff, although the checks themselves were kept at head office. The target of 50 of staff trained to NVQ level 2 or above had been exceeded. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 19 Staff spoken to confirmed they had received induction and foundation training which was to NTO specifications. The Primary Care Trust induction training programme was part of this. Staff had not undertaken the Learning Disability Award Framework accredited training. Supervision of staff had been put in place, but did not yet take place at the required level of six times per year. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 20 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) 39 42 The quality assurance system required further development to include the views of service users and their relatives/representatives on the quality of care offered by the service. There were no resident’s/relatives meetings in place at the home. There was a heath and safety policy and risk assessments were in place. Not all mandatory training of staff had been completed. There was no proper record of visitors to the home. EVIDENCE: There were comment sheets in place which sought the views of service users about the quality of care at the home. However, the quality assurance system required further development to explore the views of service users and their relatives/representatives. No information on service users views had been published. There were no service users or relatives/representatives meetings in place at the home. The team leader said that feedback from relatives was ongoing when families visited. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 21 There was a health and safety policy in place. The majority of staff had received mandatory training, including health and safety, first aid, food hygiene, moving and handling, and fire training. Additional training on person centred care planning, confidentiality, anti bullying, and code of conduct had been provided by the organisation. Staff received paid training days as required. Risk assessments to prevent harm to residents were in place. The home did not have an appropriate record of visitors. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 22 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 3 3 x x 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x 2 x x x Standard No 11 12 13 14 15 16 17 x 3 2 3 3 x 3 Standard No 31 32 33 34 35 36 Score x x 3 2 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Handsworth Development Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score x x 2 x x 2 x J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA5 Regulation 5 Requirement Contracts must be signed by residents or their relatives/representatives where possible. A review must be undertaken of community activities available for residents and attempts made to organise more trips out. Care plans must record the gender of the staff that service users prefer to support them with their personal care needs. All staff must complete the training on Adult Protection. (Previous timescale of 28th February 2005 not met). All stained lounge carpets must be cleaned. The washing machine, tumble dryer and cooker must be repaired The damaged bath panel must be replaced, and the marks on the bathroom floor must be removed. Staff recruitment files must contain all of the required documentation as detailed in the regulations. (Previous timescale of 31st December 2004 not met). J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Timescale for action 30th September 2005 30th September 2005 31st October 2005 30th September 2005 30th September 2005 31st August 2005 31st August 2005 30th September 2005 2. YA13 16 3. YA18 12 4. YA23 13 18 5. 6. 7. YA24 YA24 YA27 23 23 23 8. YA34 18 Handsworth Development Version 1.30 Page 24 9. 10. YA35 YA36 18 18 11. YA39 12 12. YA39 12 13. YA42 18 14. YA42 17 Staff must complete the Learning Disability Award Framework training. Staff must receive supervision at least six times a year and records of this must be retained. (Previous timescale of 31st December 2004 not met). Service users views of the service must be sought on a regular basis. The results of these surveys should be published and made available to all interested parties including the CSCI. (Previous timescale of 31st January 2005 not met). Efforts must be made to ascertain the views of relatives/representatives of residents, through regular meetings or other feedback systems. All staff must complete statutory training on food hygiene, first aid, fire training and moving and handling. (Previous timescale of 28th February 2005 not met). An up to date record of all visitors to the home must be maintained. (Previous timescale of 15th December 2004 not met). 31st October 2005 31st August 2005 31st October 2005 31st October 2005 31st August 2005 31st August 2005 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. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 25 Refer to Standard YA7 YA27 Good Practice Recommendations Advocates should be accessed to represent the interests of residents where possible. Bathrooms should be personalised to ensure that they are welcoming and homely and appear less clinical. Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Ground floor, Unit 3 Waterside Court Bold Street Sheffield, S9 2LR National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Handsworth Development J55 S2967 Handsworth V230023 060705 UI Stage 4.doc Version 1.30 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!