Inspection on 23/10/05 for Hartington Road Care Home

This inspection was carried out on 23rd October 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hartington Road Care Home 08/05/07

Hartington Road Care Home 09/05/06

Hartington Road Care Home 11/08/05

Hartington Road Care Home 04/03/05

Hartington Road Care Home 16/09/04

Hartington Road Care Home 24/03/04

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

CARE HOME ADULTS 18-65 Hartington Road Care Home 75 Hartington Road Leicester Leicestershire LE5 5GQ Lead Inspector Keith Williamson Unannounced Inspection 23rd October 2005 04:00 Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hartington Road Care Home Address 75 Hartington Road Leicester Leicestershire LE5 5GQ 0116 2425779 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) None Mr Mohammed Anwar Mr Mohammed Anwar Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. No additional conditions of registration apply. Date of last inspection 11th August 2005 Brief Description of the Service: Hartington House is registered to provide care for three residents with mental health problems. The home is a terrace house set in a residential area and is approximately a 10 minute bus journey from the city centre. The home was set up specifically to meet the needs of people from the Asian community. It is situated on Hartington Road opposite a community centre and close to a range of shops and local amenities. There is one single and one shared room, both of which are located on the first floor. The home has recently been re-furbished. On entering the home, there is an open plan dining room and lounge. There is a large kitchen and the toilet and shower room at the rear. The staff at the home encourage service users to maintain their independence and have daily routines. The home has a mixed skilled staff team and some able to converse in the service users first language. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over one evening, commenced at 4.00 pm and was completed in 3.5 hours by one Inspector aided by an interpreter. An opportunity was taken to view the care plans and other records in detail. Two residents were spoken with on this visit, the comments they made are included within this report; one member of staff was also spoken with. The Responsible Individual assisted with the inspection, spending time with the inspector, discussing the management of the home. Overall the Inspector recognised the three residents function very independently within an environment that meets the residents needs in an ethnically appropriate setting. What the service does well: What has improved since the last inspection? What they could do better: Policies have been provided for the home, however these have been copied from another home, are outdated and require urgent review to enable staff to have accurate reference in the home. A number of risk assessments have yet to be put in place, both for individual residents, staffing and areas covering health and safety and medication in the home. The reports from the Environmental Health and Fire Officers’ are not available in the home for inspection purposes. Proof of staff training, has yet to be evidenced and supplied. The policies and procedures though in place require to be updated with the appropriate information to enable complaints to be recorded and dealt with. Staff are not aware of the content of any plans of care, and are unaware of the residents physical and emotional needs, this being hampered by their understanding of written English. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 6 An accurate staffing rota has yet to be introduced and displayed in the home. Records of safety tests, and periodic fire alarm testing have yet to be introduced and records kept. 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. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None. None of these standards were viewed on this occasion. EVIDENCE: Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 & 9. Residents are empowered to make decisions regarding their lives. EVIDENCE: The residents are assisted to make decisions regarding their day-to-day lives and enjoy the freedom and autonomy to compliment this. Some risk assessments are in place, and these cover a number of areas personal to residents in the home; these however do not currently reflect the levels of activity the residents enjoy at this time. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. Residents are supported in a lifestyle, which is integral in the community. Residents are not supported in their personal and private relationships. EVIDENCE: All three residents have the option of joining in appropriate activities both in and out of the home. Residents feel part of the community and are able to choose when they use local leisure and community facilities. Though all residents enjoy a great deal of freedom in the home, there are some cultural restrictions placed on some of them by their peer group, so restricting their ability to enjoy personal and sexual relationships, and curtailing their fulfilment in the home. The acting manager and staff could assist in this process by increasing personal privacy levels within the home. Residents are offered a culturally appropriate diet and choose what, where and when to eat. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 11 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20. Medication is not yet administered appropriately in the home. EVIDENCE: Medication for residents is stored and administered both in this home, and at another home where residents attend on a voluntary basis, for day care. Staff transport the medication on a daily basis. There are no risk assessments to cover this daily moving of medication, nor for the resident who self-administers medication in the home, it is imperative these be put in place for residents protection. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23. Staff do not have the appropriate information and knowledge on adult protection issues to protect residents. EVIDENCE: At the point of the last inspection staff were unaware of the Adult Protection policies, procedures and terminology. This current situation remains as then, where residents are placed at risk of abuse due to staffs’ lack of knowledge. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. Residents live in a culturally appropriate and homely environment. EVIDENCE: There is a plan of routine maintenance; the acting manager keeps this up to date. The outstanding work required at the last inspection has been completed, though there appears some difficulty in obtaining the last reports of the Environmental Health and Fire Officer. The home is clean and hygienic, staff being aware of issues such as cross infection and cross contamination. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 14 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, 33 & 35. Residents are not supported by an effective staff team. EVIDENCE: Staff provide a culturally appropriate service, and can communicate in the residents’ first language. The staff in the home, are not adequately trained to deal with residents issues or emergencies, training must be provided to ensure resident and staffs’ safety in and out of the home. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 15 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 40 & 42. Residents’ rights and safety are now safeguarded by policies and procedures. EVIDENCE: The current acting manager has not yet commenced a formal qualification and is currently applying to become the registered manager. Formal residents meetings do not take place on a regular basis, though residents do feel they are listened to and have a direct influence on the running of the home. Staff in the home show an awareness of hygiene issues, though have a very limited knowledge and perception of safe working practices. Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X X X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 2 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 2 X 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hartington Road Care Home Score X X 2 X Standard No 37 38 39 40 41 42 43 Score X X 3 2 X 2 X DS0000006437.V260300.R01.S.doc Version 5.0 Page 17 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 YA9 Regulation 12(1) a Requirement The Responsible Individual must introduce a risk assessment framework for the medication system. The original timescales of the 18th April 2005 and 11th September 2005 have not been met. The Responsible Individual must introduce a risk assessment framework for the self administration of medication. The Responsible Individual must provide information to, and train staff to be aware of, and to operate, the adult protection protocols and procedures. The Responsible Individual must ensure the latest reports from the Environmental Health Officer and Fire Officer are provided for the next inspection. The original timescales of the 25th April 2005 and 11th September 2005 have not been met. The Responsible Individual must ensure that the home has in place the appropriate records of the training staff have undertaken in the home. The original timescales of the 4th DS0000006437.V260300.R01.S.doc Timescale for action 27/11/05 2 YA20 12(1) a 27/11/05 3 YA23 13(6) 27/11/05 4 YA24 13(4) c 27/11/05 5 YA32 18(1) a 27/11/05 Hartington Road Care Home Version 5.0 Page 18 6 YA33 17(2) 7 YA34 19 8 YA35 18(1) a 9 YA42 13 10 YA42 13(4) a 11 YA42 13(4) a 12 YA42 17(2) 6April 2005 and 11th September 2005 have not been met. The Responsible Individual must ensure an accurate staffing rota must be kept in the home at all times. The original timescale of the 29th August 2005 has not been met. The Responsible Individual must ensure staff working in the home are able to communicate effectively with the emergency services. The Responsible Individual must ensure the appropriate core training must be provided periodically for the staff. The original timescale of the 11th September 2005 has not been met. The Responsible Individual must ensure the provision and regular review of all policies in the home. The original timescales of the 25th April 2005 and 11th September 2005 have not been met. The Responsible Individual must demonstrate that water temperatures are kept within the recommended safe temperature range, at or near 43C. The original timescales of the 4th April 2005 and 11th September 2005 have not been met. The Responsible Individual must ensure detailed water temperature risk assessments are in place. The original timescales of the 4th April 2005 and 29th August 2005 have not been met. The Responsible Individual must ensure testing of the fire alarm system, and staff fire drills are performed periodically and records of those events kept in the home for future inspections. DS0000006437.V260300.R01.S.doc 13/11/05 27/11/05 27/11/05 27/11/05 27/11/05 27/11/05 27/11/05 Hartington Road Care Home Version 5.0 Page 19 13 YA42 18(1) a The Responsible Individual must ensure that a risk assessment is put in place for lone working is put in place for all appropriate staff. The original timescale of the 29th August 2005 has not been met. 27/11/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 4 5 Refer to Standard YA8 YA15 YA24 YA39 YA39 Good Practice Recommendations It is recommended that the acting manager involve an independent advocate to act on behalf of the residents in the home. It is strongly recommended that the privacy and support residents are offered in intimate relationships. It is recommended that the tiles to the ground floor toilet are replaced or re-laid, as they are stained and unhygienic. It is strongly recommended that after regulation 26 visits; written reports are compiled following each visit and a copy sent to the commission for social care inspection. It is recommended that staff hold regular formal residents meetings and issue minutes Hartington Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Leicester Office The Pavilions, 5 Smith Way Grove Park Enderby Leicester LE19 1SX National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © 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 Road Care Home DS0000006437.V260300.R01.S.doc Version 5.0 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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