Inspection on 26/09/07 for Hartington House

This inspection was carried out on 26th September 2007.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hartington House 02/08/06

Hartington House 16/01/06

Hartington House 16/08/05

Hartington House 28/02/05

Hartington House 29/09/04

Hartington House 11/03/04

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

CARE HOME ADULTS 18-65 Hartington House 14 Hartington Road Heaton Bolton Lancashire BL1 4DP Lead Inspector Lucy Burgess Unannounced Inspection 26th September 2007 10:00a Hartington House DS0000009315.V345943.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 Hartington House DS0000009315.V345943.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. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hartington House Address 14 Hartington Road Heaton Bolton Lancashire BL1 4DP 01204 410854 01204 493126 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) Perpetual (Bolton) Ltd Mrs Tricia Varey Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service should employ a suitably qualified and experienced Manager who is registered with the Commission for Social Care Inspection. 2nd August 2006 Date of last inspection Brief Description of the Service: Hartington House is a small care home providing residential care for up to 5 people with mental health needs. The basic fee charged is £750.00 however this may vary depending on assessed needs. The home is part of a small group of two homes (the other being Somerset House). Both homes share the same staff team and are situated near to each other in the residential area of Heaton in Bolton. There is a small office at Hartington House, although the main office base for the two homes is at Somerset House. A local company, Perpetual Care, owns the home, with the day-to-day management carried out by the Registered Manger. Hartington House is an end terrace house, consisting of 5 single bedrooms and communal areas. The house is close to a main road leading into Bolton town centre and is accessible to local amenities and public transport. Residents are generally of a younger age range at Hartington House than those at Somerset House. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced visit to the home. The inspection was carried out over one day, between the hours of 10.00am to 4.00pm. During the visit time was spent looking at paperwork and the environment as well as observing staff interactions with residents. The inspector also spoke with residents, staff and the manager. Before the inspection, we also asked the manager of the home to complete a form called an Annual Quality Assurance Assessment (AQAA) to tell us what they felt they did well, and what they needed to do better. This helps us to determine if the management of the home sees the service they provide the same way that we see the service. Feedback was given to the manager about how the form could be developed in relation to the level of information provided. Feedback surveys were also sent to service users and staff. The inspector received 2 completed surveys from residents. Comments have been included in the report. The home is registered to provide accommodation for 5 people, there were no vacancies. All the key standards were looked at during this inspection visit as well as the action identified during the last visit. What the service does well: Staff cover remains the same providing a consistent support team who understand the needs and routines of the residents. Residents appeared very settled and made the inspector very welcome. Activities take place on a regular basis and include activities both in and away from the home helping individuals to develop their confidence, independence and relationships with others. Additional support is also provided from the local mental health teams. The home has built up good working relationships with them to assist the residents in maintaining their health and well-being. The inspector spent time speaking with 3 of the residents, 2 of which had recently moved into the home. All appeared happy and relaxed to talk. The newest residents had both spent time visiting the home before moving in. One of the residents said they were, ‘settling in well’, ‘they liked the house and had everything they needed’ and ‘liked to be able to go out be themselves and do their own thing’. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Suitable arrangements should be made to ensure that risk assessments and care plans are in place when new residents move into the home ensuring staff are clear about the support required and any potential areas of risk are minimised so the people living and working at the home are safe. The manager is to provide a training matrix showing what courses staff have completed as well as what is still needed. The manager must ensure that a suitable qualified training provider provides all training. One of the areas the home should explore is annual report based on the feedback from service users and other parties about the quality of service provided and how this will inform future plans. Reports regarding the Providers monthly monitoring visits had not been done for sometime. Arrangements should be made for these completed and reports made of areas reviewed. Where incidents have occurred which may affect residents the manager must make sure that information is passed on to the CSC without delay and up dated where necessary. Redecoration and refurbishment has been on-going for some time at the home. Further work is planned, particularly to the exterior of the home. The manager is asked to provide a copy of their plan to the CSCI outlining what is planned and when they expect to complete it. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 8 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 Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 and 4 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. To ensure that the home is able to meet the needs of new residents they must ensure that detailed assessment information is available for the team prior to admission so that an appropriate decision can be made. EVIDENCE: Since the last inspection 2 new residents have moved into the home. One had moved in on a permanent basis whilst arrangements had not been finalised for the second person. This was due to funding arrangements and not issues related to the home. Both residents were spoken with and appeared to be comfortable at the home. Each of the residents had the opportunity to visit the home on more than one occasion to meet with staff and other residents prior to a final decision being made about the move. One resident said that they ‘liked the house, had everything they needed and was able to go independently’. Information was requested with regards to the assessed needs of the two residents. One file had an assessment carried out by the social worker and mental health professionals in line with the discharge programme (CPA). These was also a nursing assessment and Occupational therapist report. In the second file there was no information. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 10 The manager explained that an assessment had been received however this was held at her office on another site. Whilst staff were aware of the support needs of this individual they had not had the opportunity to read through the documentation. Prior to a new resident moving in, or as soon as following admission, clear and detailed assessment information needs to be provided so that staff are able to meet the identified needs of the individual as well as being aware of any areas of potential risk. This information should then be used to develop a care plan as neither resident had a plan of support in place. Some discussion was held with the manager about the completion of care plans, as it appeared that she held the responsibility. It was felt that some of this responsibility could be undertaken by the support team/key workers who work more directly with the residents on a day-to-day basis ensuring that information was accurate and up to date. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. It is essential that information about residents assessed needs as well as areas of risk are developed into a care plan detailing how each individual chooses to live their life ensuring both residents and staff are not placed at risk of harm. EVIDENCE: The manager explained that residents’ files had been reorganised. Each resident has 2 files, one containing assessments, plans, correspondence and old evaluation sheets, whilst the second file was used on a daily basis. This included daily evaluation sheets, medication records, finance sheets, health information such as weight and appointments. Files for the newest residents were explored. It was found that no care plan or risk assessments had been developed for either resident. Whilst those staff spoken with appeared to understand the needs of the residents and had quickly established a good rapport information is needed so that staff have the relevant guidance on how support is to be provided, ensuring potential risk is minimised. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 12 Information held on one file, as already stated, was detailed with regards to assessment information as well as a ‘pre-care plan’, which outlined what the home could offer to meet the identified needs. This information was clear outlining the persons’ diagnosis, skills, family, vulnerability, risks and behaviour. Records also showed that the resident was under a formal discharge plan (CPA), minutes of these meetings should also be held on file. Whilst it is acknowledged that final arrangements in relation to placement have yet to be made a short-term plan is required in relation to the support offered as well as evidencing how risk is being minimised. The second file only contained daily records. However from talking with the resident and staff it was apparent that they had identified potential risks and support needs with regards to compliance with medication, epileptic seizures, finances and behaviours. A report was also held on file regarding an alleged incident, which had taken place in the community. This had resulted in the police being called. The manager must ensure that information is forwarded to the CSCI in line with Regulation 37. The inspector later visited the 2nd home to speak with the manager and was shown information, which had recently been received about the second resident. This had been provided following admission and outlined the residents’ mental health history and behaviours, which included some areas of concern. Each of the other residents have detailed plans, assessments and review notes addressing their identified support needs as well as monitoring their mental health and well-being. As already identified the responsibility of developing care plans and risk assessments is usually left to the manager. It was discussed if other staff could be more involved in this process. This would support the manager as well as ensuring information was gathered more promptly. The manager agreed with this. Staff also use a communication diary where information about the home and residents’ is recorded and used for the handover. As the home is relatively small, informal day-to-day contact is made between residents and staff with the views and opinions of both parties being easily aired. The new residents both expressed that the staff had ‘helped them’ and ‘were great’. The staff team has remained stable and team members were found to have a good awareness of individual needs. Two other residents provided feedback in the surveys sent out prior to the inspection. Both stated ‘always’ or ‘yes’ to questions about making decisions about what to do each day, I can do what I want to do, knows who to speak with if unhappy, how to make a complaint and that the staff treat them well and carers act and listen to what I say. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 13 Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home respects the individuality of residents, offering support to promote their independence. EVIDENCE: None of the residents at present have chosen to be involved in any formal employment or college courses, preferring a more relaxed routine. Each of the residents currently living at Hartington have very different skills and abilities. Each follow their own routines, which are in the main independent of each other. Some of the support is offered on a 1-2-1 basis. Residents are able to rise as they choose, this is dependent on individual plans. Daytime activities vary depending on individual preferences both in and away from the home. Whilst residents are able to come and go as they wish, there is an expectation that individuals are back at the home by 11pm so that staff can ensure that the building is secure. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 15 Those able to travel independently do so however the home does have access to a vehicle, which is used for outings as well as appointments. Some of the activities residents are currently involved in include, attending the local drop in. One resident attends the women’s group whilst other residents mix with other people who attend from the local community. Residents visit local pubs and shops, another resident enjoys going to Bingo and trips have been taken to Rivington and Moss Bank Park. At home residents play cards, watch TV and DVD’s and listen to music. One resident has done some baking. Residents were seen to spend time in the privacy of their own rooms as well in the communal lounge. Identified at the last inspection was the use of a notice board displaying leaflets from local places of interest. These are to provide the residents with some ideas for day trips etc. Staff are requested to keep this up dated so that residents can explore other opportunities they may be interested in. Suitable arrangement are in place in relation to personal mail. This is received by residents unopened, however some support from staff is provided where necessary or a response is required. As previously identified the practice of providing keys to rooms continues however residents are not routinely given a key to the front door due to areas of risk and in the main the home being occupied. Residents continue to have contact with family and friends either by telephone or visits to each other homes. Contact is made on a regular basis. Where necessary specific agreements have been made with regards to home visits, these are monitored and reviewed. Meal times are relaxed, again due to individual preferences and routines. Those wishing to cook can with the support of staff if needed. One resident is able to manage independently. Residents are encouraged to prepare there own breakfast and lunch with the evening meal generally being prepared by staff. There is an occasional take-away. The inspector looked at the food stock held in the basement, this included fresh, frozen, dried and canned goods. Further provisions were also available with regards to halal foods as one resident follows a halal/vegetarian diet. The kitchen was not accessible due to work being carried out to replace the boiler. It was noted however that new dining furniture had been purchased. Residents are encouraged to follow a healthy diet and staff continue to monitor meals and weight. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The health and personal care needs of residents are continually monitored and reviewed to ensure the well-being of residents is maintained. EVIDENCE: Residents are monitored and encouraged to address their own personal care needs however where such support is needed staff will assist. This is dependent on the needs of each resident as at times this is an area, which is neglected due to the behaviours of residents. In relation to the physical and emotional needs of residents it is clear that staff have a good understanding of individual needs, which is assisted by having a stable consistent team. Further support and advice is provided by health and social care professionals involved. For the new residents who had recently moved into the home, arrangements had been made with regards to registering with a doctor etc. As some residents living at the home are there as part of an agreed discharge programme (CPA) regular review meetings are held to ensure their mental health and well-being is maintained and medication is reviewed. Staff have Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 17 also received some in-house training in epilepsy due to the needs of one resident and information about Korsakoffs is available due to the needs of another resident. More formal training may need to be considered for staff due to the needs of the resident with epilepsy. Through discussions with the manager and senior it was noted that the resident has had several seizures during the short period living at the home and 2 incidents have resulted in attending A&E. Where residents require additional health support, the home has accessed the support of occupational therapists, incontinence nurses and assessments regarding aids and adaptations. The home also has support from a mental health advocacy group, MHIST. Meetings have not been held for a while due to the advocates availability, however these are to resume. This give residents a further opportunity to discuss any issues they have as well as receiving additional support. Records continue to be made of all professional visits and appointments, which include community psychiatric nurses, GP, dentist, hospital etc. Each resident has access to all NHS entitlements as and when they are needed. Support is offered for appointments. The medication system was looked at and found to be safe. Items are held securely in the staff office. At present none of the residents are in receipt of controlled drugs. Records are held on individual files and had been completed in full including the stock received. Further records are made of all items returned to the supplying pharmacy. The home continues to monitor the administration of medication. The supplying pharmacist also carries out periodic audits. As already stated residents’ medication is also regularly reviewed with health professionals ensuring the stability of their mental health. One resident continues to refuse all medication prescribed. The relevant health professionals and staff monitor this. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies and procedures as well as staff training are in place to ensure that residents are listened to as well as being protected. EVIDENCE: The home has copies of the Local Authorities Vulnerable Adults Policy and Safe Guarding Adults Procedure along with their own policies and procedures. Where necessary the manager would liaise with personnel from the safeguarding team if she had any concerns, ensuring procedure is followed and individuals are protected. Staff have also been provided with training in this area. Since the last inspection there have been no issues or concerns raised at the home as identified on the AQAA or directly with CSCI. As previously identified the home also has additional policies and procedures in relation to the protection of residents. These include whistle blowing, aggression, service users finances and missing persons. All staff have a Criminal Record Check in place. Clear procedures are in place with regards to the handling of residents’ money. One of the newest residents manages their own affairs without the support of staff. Support is provided where necessary and agreed budget plans are in place. Records are made of all transactions as well as receipts being held. A random sample was checked, no errors were found. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. On-going work is being carried out to improve the appearance of the home so as to provide a comfortable home for those who live there. EVIDENCE: As previously identified Hartington House is a small home set within a residential area of Bolton. Accommodation consists of 2 lounges, one of which is the staff sleep-in room, a dining kitchen, 2 bathrooms and 5 single bedrooms. There is also a staff office on the second floor and laundry facilities in the basement. Residents are able to personalise their rooms if they wish Most of the work identified at the last inspection has been carried out. This included the condition of one of the bedrooms. The inspector asked the resident if she could look at the work carried out. There had been great improvement to the room as it had been redecorated, new flooring fitted and the radiator fixed and secured to the wall. The room looked clean and tidy. During the visit work was being carried out to replace the central heating boiler. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 20 The front garden was tidy and nicely presented, outdoor furniture was available. The manager said that the work had been done by one of the residents who likes to garden. One area previously identified, which has still yet to be completed was in relation to the exterior of the home. The manager explained that work has been planned to replace the fascias, paint outside, have a new roof and repoint the walls. Completion of this work is dependant on the weather. Other work, which was identified included; • Suitable arrangements need to be made with the new resident whose belongings have been stored along the hall way on the second floor. This does not provide ease of access in the event of an emergency • Items were being stored within the electric meter cupboard. These need to be removed. • Closing devise on one of the bedroom doors was broken. This needs to be repaired. The manager is asked to forward a plan of action in relation to the work required along with dates for completion. Arrangements have been made with regards to a smoking area. Aids have been fitted within the home to provide assistance for one resident who had difficulty with his mobility. Handrails have been fitted at the front door, an extra handrail to the stairs and a grab rail in the bathroom. The staff continue to carry out most of the domestic tasks however residents are encouraged to assist. Hand washing facilities are in place in both the kitchen and laundry to ensure the prevention of cross infection. All staff are due to receive training in this area. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A safe system is in place for the recruitment of staff as well as a programme of training so that staff have the knowledge and skills needed to meet the needs of residents. EVIDENCE: As previously identified the staff at Hartington House also work across at the sister home, Somerset House. Double cover is provided at the home on a 24hour basis, with sleep-in staff at night. Information in relation to staff recruitment files were not looked at, as there has been no changes within the team since the last inspection visit. At present the manager is recruiting a new member to the team who has previously worked for the organisation however prior to commencing shifts on the rota the manager is awaiting references and a Criminal Record Check. A lot of work has been completed with regards to NVQ training level 2 and 3. Of the 11 staff, 5 have completed level 2, 3 have progressed to level 3, 1 has already completed level 3 and another member of staff is to commence level 2. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 22 The means that approximately 60 of the team have completed the training. Four other staff members are already undertaking social study courses. The manager has now completed her NVQ level 4/Registered Managers Award. Copies of the certificates have been received by CSCI. The organisation has been involved with Bolton Partnerships for some time, this enables them to access training opportunities. Courses recently completed by some staff have included medication level 2, moving and handling and first aid at work. In-house training has also been held with regards to epilepsy. The manager stated that 4 staff have yet to attended medication training, dates have been planned and that all staff were receiving training in infection As courses become available through the control on the 5th October. partnership the manager tries to accommodate staff. She is asked to provide the commission with a training matrix identifying staff training along with dates of completion and any future plans. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The manager is aware of her responsibilities in ensuring areas of health and safety are addressed so that the home is run in the best interests of residents. This could be developed with regards to quality monitoring to provide an annual report, which includes the views of those who use the service as well as other stakeholders. EVIDENCE: Whilst the manager is responsible for Hartington House her office is based at the sister home at Somerset House, however regular contact and visits are made to the home. The manager is supported in her role by senior support workers who take on some additional day-to-day responsibilities. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 24 The manager undertakes periodic training to ensure she is aware of current good practice. She has previously gained the NVQ level 4 and has recently achieved the Registered Manager Award. Copies of her certificates have been provided to the CSCI. Discussion was held with the manager about the new inspection process. As already stated the manager had completed and submitted the AQAA prior to the inspection taking place. The manager was advised about what other information could be provided within the assessment expanding on evidence about the work being carried out by the home. The manager has recently completed the National Minimum Dataset information for Skills for Care. With regards to quality assurance, both the manager and staff speak with residents on daily basis. This is on a more informal basis rather than formal meetings. Families also continue to be involved. Further feedback is also sought from residents, their families and health professionals through the formal review meetings which are held and questionnaires, which have previously been distributed. Staff feedback is also sought during the periodic team meetings and supervision sessions. In relation to monitoring by the Provider, Regulation 26 visits have not taken place for sometime. Arrangements should be made and evidence of such visits held within the home. As previously identified the manager still needs to look at formalising a way of gathering the information that people have provided, which can then be summarised into a report, outlining areas of development for the forthcoming year. A copy of the report should be supplied to the CSCI. A copy should also be available to residents and others, so that they know that their comments are being noted and acted upon, where necessary. In relation to health and safety regular checks are carried out by the staff. This includes a weekly check of both the inside and outside of the building, fire safety and water temperature. A recent fire drill had been undertaken involving staff and all residents. As previously identified the records should identify, which area has been checked. The manager who has been trained to carry out such task undertakes checks in relation to small appliance. Further checks are also carried out with regards to the electrical wiring, gas safety and fire alarm and equipment. COSHH assessments had been reviewed an up dated. The inspector was informed of an incident, which had occurred outside of the home. This information should be forwarded to CSCI initially at the time the incident occurred and then followed up by what action has been taken to address any issues arising. Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 25 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 2 3 X 4 3 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 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 2 X Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 26 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 YA2 Regulation 12 Requirement Detailed assessment information in relation to the needs of new residents should be available to the team prior to any new placement commencing ensuring that the team can meet the identified needs. On admission a care plan should be developed offering clear guidance to the staff so that consist support is offered. Where areas of potential risk have been identified a detailed risk assessment should be undertaken identifying action to be taken to minimise such risk ensuring the safety of residents and staff. Arrangements should be made for the Provider to undertaken the monthly monitoring visits in line with regulation and evidence of such visits are available at the home. Any incidents affecting the wellbeing of residents should be reported to the CSCI and followed up with any action taken to ensure the safety of residents. DS0000009315.V345943.R01.S.doc Timescale for action 30/11/07 2. YA6 15 30/11/07 3. YA9 13 30/11/07 4. YA39 26 30/11/07 5. YA42 37 30/11/07 Hartington House Version 5.2 Page 27 6. YA42 23 That the record of water temperatures identifies, which areas have been checked ensuring the safety of residents. (30/09/06) 30/11/07 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 YA6 YA9 Good Practice Recommendations The manager should explore with other senior staff their involvement in developing care plans and risk assessments. Where this identifies any training and development this should be provided so that information is that information is detailed and supports both residents and staff. A copy of the homes refurbishment plan should be forwarded to the CSCI outlining the work identified and timescales for completion. A copy of the staff training matrix should be forwarded to the CSCI outlining training completed by staff and futures plans along with relevant dates and training provider. That a report in respect of all quality reviews is written outlining the development plan for the home and made available to all interested parties. 2. YA24 3. YA35 4. YA39 Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Manchester Local office 11th Floor West Point 501 Chester Road Manchester M16 9HU National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Hartington House DS0000009315.V345943.R01.S.doc Version 5.2 Page 29 - 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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