Inspection on 09/02/06 for Hascot House

This inspection was carried out on 9th February 2006.

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 no outstanding requirements from the previous inspection report, but made 17 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hascot House 21/09/06

Hascot House 16/08/05

Hascot House 21/03/05

Hascot House 07/10/04

Hascot House 24/03/04

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 Hascot House 243 Gleadless Road Sheffield South Yorkshire S2 3AL Lead Inspector Mr Rob Curr Unannounced Inspection 9th February 2006 09:00 Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 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 Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 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. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hascot House Address 243 Gleadless Road Sheffield South Yorkshire S2 3AL 0114 258 8895 0114 258 8895 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) Valeo Limited ** Post Vacant *** Care Home 9 Category(ies) of Learning disability (9) registration, with number of places Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2005 Brief Description of the Service: Hascot House is a detached, domestic style, two-storey building providing care for nine adults. It is in a residential area of Sheffield with good access to public services and amenities (e.g. bus services, shops, libraries etc). It is well decorated, with single rooms and has a suitable lounge and dining room. The gardens are landscaped and it has a car park. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection began at 9.30 a.m. and lasted 2 and a half hours. All but one of the key standards were inspected during the last inspection therefore progress on requirements and recommendations made during recent visits to the home were assessed. The inspector undertook on a partial tour of the home. A limited of policies, procedures, and records were checked. Janice Gray the senior project worker, was present during the inspection. The inspector discussed practice at the home with her and another staff member. All but one of the residents were out. The one remaining resident was particularly helpful during the inspection process. He was willing to discuss his experience and life style at the home. The staff were helpful and assisted the inspector throughout the visit. What the service does well: What has improved since the last inspection? The medication records were clear and accurate. Plans to create further office space were on-going. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 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 Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 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): 5 All service users had an individual contract. EVIDENCE: All the service users’ files contained a copy of their ‘Contract/Terms and Conditions of Residency’. The service user and or their representative had signed these. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 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, 8 and 9. All of the above key standards were checked and met during the last inspection. Risk assessments to minimise any risks associated with the resident’s lifestyles had been devised. EVIDENCE: One risk assessment was checked. It did not contain all of the relevant information in order to minimise risks to the identified resident. The staff said that the risk assessment around the individuals control and restraint was reviewed on a regular basis; however, this assessment was not signed and dated. The service user that met with the inspector expressed their views in relation to being involved in the management of the service. He said that they had regular service user meetings. These were an opportunity to identify ones needs and wishes. He said that the staff were Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 10 ‘very supportive’ and that he could ‘depend on the staff to promote his independence’. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 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 the following standard(s): 12,13,14 and 15. All of the above standards (11-17) were checked and met during the last inspection. However, systems need to be in place for when service user’s choices are restricted. EVIDENCE: One resident said that all his social needs were highlighted in his ‘care plan’. He also said that the staff team encourage him to contribute to his family life and enhance relationships. There were occasions recorded when one resident had his movements and access around the house restricted. There needs to be a clear recording system that highlights the reasons and benefits when a service user’s freedom of choice is restricted. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 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): 19 and 20. The information within the care plans was very clear. Health care was monitored and care plans were reviewed. This ensured the well-being of the residents. A range of health care professionals worked within the home to assist in meeting the needs of the residents. Residents could choose their GP and could see them in private so that their privacy and dignity was respected. All medication administered was signed for. EVIDENCE: The care plans were checked. They contained detail of the action required by staff to meet the residents needs. The plans contained records of health assessments such as moving and handling. One service user said that he was ‘very happy’ with the care they received and that he had a named ‘key-worker’. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 13 Medication Administration Records (MAR) were checked. Staff had signed to indicate that medication had been administered. Staff were observed respecting service users privacy by knocking on bedroom doors before entering. During the lunchtime meal, staff were seen and heard encouraging a resident to consider and prepare his meal. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 14 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 and 23. Service users views are listened to. One residents risk assessment around physical interventions was not comprehensive enough. EVIDENCE: One resident explained to the inspector how he is supported to make his feelings known. He said that he was encouraged to ‘speak out’ at house meetings. Working practices for physical interventions and dealing with challenging behaviours need to be addressed. The policy and procedure did not include: • Date of last review • Identified benefits • No indication it was developed by the team • Who can implement the intervention • When it should stop/time limits • Details of who prescribed/approved the intervention The reports of the restraint actions taken did not contain sufficient detail. All training that is offered to staff must be accredited by BILD (British Institute for Learning Disabilities). The staff were unable to confirm this, however, the organisation does have a dedicated ‘key trainer’ that delivers physical intervention training to the staff team. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 15 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 and 30. Service users live in a homely and comfortable environment. The identified refurbishment programme was being maintained. EVIDENCE: The service users clearly enjoy their living space. One person talked with a positive attitude about any decoration work that had improved their home. The outside area was tidy and well kept. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 16 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 and 35. The recommendation that 50 of the care staff team are qualified to National Vocational Qualifications (NVQ) level 2 in care had not yet been achieved. Staffing levels were changed without consultation. EVIDENCE: The night staffing number had been reduced to one (1) waking night staff and one person ‘on-call’ from home. This was arranged without consultation with the Commission for Social Care Inspection. These numbers contradict the agreed staffing statement of 2002. The Manager assured me verbally that this had been implemented with immediate effect. This practice could compromise the safety of both the residents and the staff working alone. A group of staff were currently undertaking National Vocation Qualification (NVQ level 2 & 3) in direct care. Staff confirmed that they received more than 3 days paid training each year. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 17 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): 37,38,41,42 and 43. The service users informed the inspector that the organisation constantly monitors the service. EVIDENCE: One resident said that he had ‘every confidence’ in the manager and his staff team. Monthly monitoring visits have not been reported to the local office of the CSCI since September 2006. These reports are required by regulation as they reflect whether the organisation is proactive at identifying good practice within the service. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 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 X 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 2 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 3 X 2 3 X 2 2 2 2 Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 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 Standard YA9YA6 Regulation 37 Requirement Timescale for action 07/04/06 2 YA42YA40YA16 37 The risk assessments in relation to physical interventions must be reviewed to include current guidelines. 07/04/06 Any sanctions imposed with regard to service users ‘activities’ should be recorded appropriately. Taking into account: • Details of activity/behaviour leading up to the use of the sanction • Description of the sanction used • Time date and location of sanction • Name of person/persons imposing the sanction • Effectiveness and consequences of the sanction The policy and procedure around physical intervention need to clearly identify: 07/04/06 3 YA42YA7YA16YA23 37 (7)(8) Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 20 • • • • • • Date of last review Identified benefits An indication it was developed by the team Who can implement the intervention When it should stop/time limits Details of who prescribed/approved the intervention 07/04/06 4 YA7YA6YA23 37 5 YA42YA32 18 The organisation must confirm that the principal trainers that deliver physical intervention training are accredited by BILD. The staffing levels for the night duty must be increased to the agreed level of one waking night staff and one ‘on-call’ in the building. You may choose to allocate the ‘oncall’ role as a second waking night staff. The agreed staffing statement of 2002 must be adhered to. The recently recruited manager should apply to register with the Commission for Social Care Inspection. 09/02/06 6 7 YA42YA32 YA37 18 8 09/02/06 07/04/06 Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 21 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA16 YA32 Good Practice Recommendations The plan for the manager to have a separate office to conduct private and confidential business should continue. Continue the plan to ensure that 50 of all care staff has a qualification of NVQ level 2 or equivalent. Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr Doncaster DN4 5HZ 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 Hascot House DS0000002970.V275704.R01.S.doc Version 5.1 Page 23 - 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. 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