Inspection on 10/07/06 for Hardy Drive (23)

This inspection was carried out on 10th July 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hardy Drive (23) 07/06/07

Hardy Drive (23) 06/01/06

Hardy Drive (23) 06/09/05

Hardy Drive (23) 21/02/05

Hardy Drive (23) 16/08/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Hardy Drive (23) 23 Hardy Drive Royston Hertfordshire SG8 5LZ Lead Inspector Mrs Judith Kent Key Unannounced Inspection 10th July 2006 2:00 Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hardy Drive (23) Address 23 Hardy Drive Royston Hertfordshire SG8 5LZ 01763 243 684 01763 245 972 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 Diane Elizabeth Evans Care Home 6 Category(ies) of Learning disability (6), Physical disability (1) registration, with number of places Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. This home may accommodate up to 1 place for a person with physical disability associated with learning disability. 6th January 2006 Date of last inspection Brief Description of the Service: Hardy Drive is a small home, which accommodates six service users who have learning difficulties, one of whom may have a related physical disability. The home is situated on a housing estate in Royston and blends in with the local housing. It offers a large lounge, conservatory, kitchen/dining room, and relaxation/sensory room on the ground floor. One bedroom with en-suite is on the ground floor, which accommodates one service user with a physical disability. There is a chair lift providing access to the first floor for some one with a physical disability. The first floor contains five further bedrooms, a bathroom, shower room and the staff office/sleep-in room. A large garden to the rear of the house offers a relaxing area for service users to enjoy the nice weather. The building is owned by Aldwyck Housing which is responsible for maintenance although the care service is provided by Mencap. Fees range from £548.33 - £641.12 per week. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over almost four hours during the afternoon. On arrival one service user was at home, the remaining five were at various activities or centres outside the home, but all returned later during the inspection. The manager was not in the home during the inspection which was conducted with the help of the senior support worker and other staff members and service users. All the service users contacted during the inspection or who sent questionnaires back said that they were happy living at Hardy Drive and found the staff helpful – ‘I like living at Hardy Drive…..’; ‘I rely on staff support to know what I like doing’ The atmosphere in the home was relaxed with service users and staff interacting well and working together to make their evening meal. What the service does well: What has improved since the last inspection? What they could do better: Procedures must be tightened to make sure that service users are given the correct medication and that it is recorded accurately. Repairs and maintenance are often subject to long delay, leaving some facilities unavailable to service users. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 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. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 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 Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home carries out full needs assessments for prospective service users to make sure that needs can be met and that the home is a suitable environment. EVIDENCE: There have been no new admissions to the home for several years, but previous inspections have shown that full needs assessments are completed by the home staff before service users are invited to move in. They are offered an opportunity to visit the home and meet other service users to help them to make a decision. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 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, 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users needs are met by the staff group and they are enabled to make decisions and choices about their lives in the home. EVIDENCE: Care plans looked at during the inspection showed that service users’ needs and how their personal objectives can be met are recorded, along with regular reviews. Risk assessments are in place. User-friendly formats have been developed recently and have been incorporated into some service users’ files helping to ensure that they are fully involved in making decisions about all aspects of their lives. Each person is also given a copy of the Service Users’ Guide and templates of letters that they may need to use if they need to contact, for example, outside agencies such as the CSCI. A decision had been made before the last inspection that the home was no longer meeting the changing needs of one service user and an extensive consultation process is underway to find a more appropriate home where the person’s needs can be more fully met. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 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, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users can engage in a variety of activities and are given opportunities to maintain a good quality of life in the home. EVIDENCE: The staff enable service users to engage in a varied range of leisure and educational activities and to be involved in the local community. Everyone at the home attends day centre and learning experiences on several days each week and ad hoc and planned outings are part of everyday life in the home. No-one is currently doing paid or voluntary work outside the home. Service users are encouraged to take responsibility for their decisions and actions and are helped to do so by the staff group; the relationship between staff and service users is relaxed and supportive. Menus are planned together with the help of a picture menu book and service users shop and are involved in the preparation and cooking of meals. Everyone seemed to enjoy their evening meal on the day of the inspection. A dietician is consulted if there are concerns about nutrition or excessive weight gain or loss. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 11 Service users are encouraged to maintain family links and relatives are welcomed into the home. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 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, 19, 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users’ physical health is maintained and they are given appropriate social and personal support. Errors in medication recording and administration could place service users at risk. EVIDENCE: Care plans describe how service users wish to be supported and set out details of healthcare interventions by health professionals. There is clear evidence to show that service users who need additional support from both the home and other agencies receive the care and support that they need. While the majority of the medication looked at was reconciled to the Medicines Administration Record (MAR) sheets there was a discrepancy in one person’s Diazepam. The support worker was unable to offer an explanation for this and said that the medication and records were audited regularly to eliminate such discrepancies. Recording of medication to be returned to the pharmacy was unclear and the advisability of one person taking responsibility for this process was discussed. All staff members have had training in medication administration. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their relatives can be confident that they will be protected from harm by the policies and procedures in place in the home, and that their concerns will be listened to. EVIDENCE: There have been no complaints or allegations of abuse since the last inspection, although one service user has been displaying challenging behaviour to both staff and other service users. This is fully documented and there are measures in place to protect the other people living in the home, e.g. an additional member of staff is on duty at all times to enable appropriate management of challenging behaviour. Service users are given guidance in the Service Users’ Guide on how to use the complaints procedure or to express any concerns they may have. Staff members have an awareness of policies and procedures relating to the protection of vulnerable adults. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users live in clean, comfortable, homely surroundings, although there are some areas of the home which they are currently unable to use as they are in need of repair. EVIDENCE: A tour of the home revealed that service users’ rooms are individually decorated according to their choice of colour and style and reflect their personal tastes and interests. The communal areas – lounge, kitchen and dining area – are comfortable and appropriately furnished. The boiler in the kitchen needs repair – although in working order, the bottom part of the casing has broken away and is held on by tape, and could prove hazardous. The sensory/relaxation room has recently suffered a collapse of the ceiling due to a water leak on the first floor and is awaiting repair. Although one toilet on the ground floor was out of action due to a broken toilet seat, the remaining bathrooms and toilets were clean and well-kept and the damp patch in one bathroom noted in the last report has been repaired. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 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): 32, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users in the home benefit from a well-trained, competent and effective staff team. EVIDENCE: The staff group at Hardy Drive has had few changes for some time giving service users continuity and stability. Training records looked at during the inspection showed that mandatory training has been completed and that in addition Mencap offers a wide range of courses relative to the service user group for staff to take up. Records showed that individual supervision is given to staff at least every six weeks and there are regular staff meetings where issues of general concern can be discussed. Staff recruitment records were not available during the inspection as they are kept locked in the manager’s office. However, the CSCI has previously had no concerns about the recruitment and staff management process and records will be looked at at the next inspection. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 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): 37, 39, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users welfare is protected by the health and safety procedures in the home, although there is risk of accident in some areas to which access should be restricted until repairs are completed. Service users’ views are listened to and acted upon. EVIDENCE: A new manager has recently been appointed to the home who has been registered with the CSCI. The staff team are in a period of adjustment to the new manager, who has made changes in the home since her arrival. The staff members on duty during the inspection said that they found her supportive and approachable. Health and safety records were seen and were in order and the necessary checks have been completed and recorded. Financial processes for managing service users’ money were looked at and are in order, although there is no apparent external audit of the records. There are regular meetings for service users, facilitated by a staff member, to discuss issues arising from how the home is run and to plan activities etc. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 17 There are regular monthly visits to the home by a Mencap representative who carries out quality assurance checks and reports to the CSCI. The sensory/relaxation room in the home, where the ceiling had fallen down, had a notice instructing not to use it attached to the handle, but was unlocked, as was the toilet with the broken seat. These doors should be locked to prevent entry and possible accident. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 18 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 x 2 3 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 x 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 3 x 3 x x 2 x Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 19 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 2 3 Standard YA20 YA24 YA42 Regulation 13(2) & 17(1) Sch 3 13 (4) (a) 13 (4) (c) Requirement Medication records must be accurately maintained. The sensory room and ground floor toilet must be repaired and brought back into use. Access to the sensory room and the ground floor toilet should be restricted until the necessary repairs are carried out. Timescale for action 10/07/06 31/08/06 10/07/06 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. Refer to Standard YA20 Good Practice Recommendations It is recommended that one person be nominated to be responsible for managing medication returned to the pharmacy. Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 20 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ 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 Hardy Drive (23) DS0000019404.V302881.R01.S.doc Version 5.2 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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