Inspection on 14/03/06 for Hawkstone House

This inspection was carried out on 14th March 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hawkstone House 09/07/07

Hawkstone House 01/12/06

Hawkstone House 27/07/06

Hawkstone House 22/11/05

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 09/07/2008.

CARE HOME ADULTS 18-65 Hawkstone House Shann Lane Keighley West Yorkshire BD20 6NA Lead Inspector Michael Smithson Unannounced Inspection 14th March 2006 10:00 Hawkstone House DS0000064324.V284451.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 Hawkstone House DS0000064324.V284451.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. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Hawkstone House Address Shann Lane Keighley West Yorkshire BD20 6NA 01943 865654 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) Isand Ltd Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd November 2005 Brief Description of the Service: Hawkstone House is large detached house standing in its own grounds. Its proximity to Keighley town centre gives easy access to shopping, transport links and leisure facilities. All the bedrooms are singles with one being en-suite. A large dinning and separate lounge area are provided. The home provides accommodation for 6 adult service users with learning disabilities who require significant support in daily living and may present with challenging behaviour. Service users would be in the age range 18 to 65 and of mixed gender. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over the morning and early afternoon of the 14th March 2006. This was the second visit for this year, the first being an announced inspection. Copies of reports for this and the last inspection are available on the CSCI website. This inspection focused on the environment, service user records and any outstanding requirements and recommendations from the last inspection. Time was also spent talking to staff and service users. The home has been opened nearly 12 months and has had one change of registered manager. The current manager had not made an application to become registered at the time of writing the report. The home has slowly filled since opening giving new service users adequate time and staff attention to allow them to settle at the home. The manager and the staff are clear as to the levels of care they can provide. There was a significant delay in the provider and manager receiving the first annual inspection report from CSCI. This has lead to some delay in the progress made with the requirements and recommendations made at the last inspection. What the service does well: The layout of the home is organised like a family home and this helps to create the general atmosphere of a friendly family environment for service users to live. The pre-admission assessment information is very detailed and provides very good information about service users. This helps to determine that appropriate service users are placed at the home and will benefit from the care philosophy. A very good range of activities is offered for service users including outings, leisure pursuits and arts and crafts. The staff are keen to involve the service users in the local community. Service users are encouraged to contribute to the decision making process and are offered a very good level of choices. The staff demonstrated a good understanding of service users individual needs and were aware of there responsibilities as key workers. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: The statement of purpose and service user guide must be available in a userfriendlier format. The manager’s registration application must be completed. The service user plan must be produced in a format, which reflects the wishes and aspirations of service users. It should be produced in a more user-friendly format. The complaints procedure must be produced in a more user-friendly format. A system for recording complaints must be available. Adult protection training must be organised for all staff. The staff recruitment records must include a reference from the last employer. Any gaps in the information supplied by applicants must be properly checked. A start date and the numbers of medication supplied must be included on the drug administration records. The accident recording system must be revised to allow staff to include more detail of the accidents. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 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. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 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 Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 4. Hawkstone House provides prospective residents with information regarding the home, however the format needs to be more suited to their communication needs. The homes admission procedure allows residents the opportunity to visit the home prior to admission. EVIDENCE: The final version of the new statement of purpose and service user guide have not yet been completed. Some information regarding the home is available in the brochure. A very comprehensive pre-admission assessment is available. The records for the last admission included a completed assessment undertaken during a domiciliary visit. The assessment included information regarding the social and health care needs of the service user. The information allows the staff to determine that they are able to meet the service users needs. A trial visit is included in the admissions procedure. The length and frequency of the trial stay is determined by the individual needs of the service users. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 10 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, 8 and 9 Detailed assessment and care plans are produced, however again the format must be changed to reflect the views of service users. Risk assessment is used to help residents take acceptable risk and maintain independence. Service users are encouraged to make choices in their daily lives. EVIDENCE: The care plans for a recent admission were checked during the inspection. All the information required was available, however the care plans are in the process of being changed to a more individual person centred format. The care plans and reviews are updated by the key workers. The key worker present during the inspection showed a very good understanding of the needs of the service user and had documented any progress or deterioration. The care plans include detailed risk assessments for individual service users. The risk assessments include safety aspects of any self-care tasks. Good levels of communication exist between the changing shifts, which allows good continuity of care. The night staff complete a separate night report, which includes codes and regular checks to identify any patterns of behaviour. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 11 Service users are consulted on all aspects of daily life. This happens both individually with key workers and at the house meeting. The staff and the service users meet to discuss the menus, planned activities and daily routines. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 12 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): 11, 12, 13 and 14. A very good range of activities are offered which allow residents the opportunity to engage in appropriate leisure activities. EVIDENCE: All the service users have the opportunity to make decisions, which affect their lives at the home. This encouraged personal development and positive contribution. An excellent range of activities is offered to service users. These take place both in groups and one to one. Activities are both planned and can be spontaneous. A good range of indoor activities is offered including, games and arts and crafts. The service users are encouraged to use facilities in the local community, including shops, restaurants, sports facilities and the local library. Links are being established with local colleges and work schemes. Plans are being discussed to help find appropriate placements for service users. The service users are involved in the daily duties and routines and are encouraged to keep their personal space clean and tidy. They help with the Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 13 cleaning of the communal space and help in the kitchen. Service users also accompany staff on the food shopping trip. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 14 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. The recording of medications brought into the home must be improved. EVIDENCE: The home currently use the Boots Blister Pack monitored dosage system. However they are planning to change to a new provider who operates a similar system. A spot check of the medication was undertaken. Lockable facilities are provided for the safe storage of medication. Records of administration are well recorded. The only issue noted regarding the medication was the need to remember to book in the numbers and start date of the medications not included in the blister packs. This usually includes PRN medication. It did appear to be completed on most MAR sheets but had not been completed on those currently being used. A stock check cannot be undertaken without this information. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Residents are protected from abuse, however the adult protection training does need to be improved. The complaints procedure needs to be more accessible for residents. EVIDENCE: The manger has now obtained the local authority No Secrets guidance and appropriate contact numbers are available. Training is being organised for the staff team. The complaints procedure still needs to be produced in a more user-friendly format. The information must be available in the service user guide. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30. The environment meets the needs of the service users and provides a family domestic type environment. EVIDENCE: A full building inspection was undertaken during this visit. The home is currently being extended with builders on site. However the building area is being kept separate from the current living arrangements and very little disruption has been noted. The home provides 6 single bedrooms. One on the ground floor and the remainder on the first floor. The bedroom on the ground floor is sited next to the office and is used by a service user who requires regular supervision and monitoring. The service users are encouraged to keep their bedrooms clean and tidy with the support of the staff team. Bedrooms are being personalised and some service users have chosen to purchase their own bedroom furniture. All except one of the service users are offered a key to lock their bedroom doors. The exception is the bedroom on the ground floor, which requires close monitoring during occupancy. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 17 Bathrooms and showers are available and were maintained to a good standard of hygiene. Service users have their own personal toiletries, which they take with them when using the facilities. The communal areas consist of a large lounge, dinning area and a sun lounge, which is used as additional arts and crafts space. The communal areas are decorated and furnished in a domestic style, which helps to create a homely feel to the space. The kitchen and the laundry are well organised and can be accessed by the service users. The staff do provide support and assistance when service users use these areas. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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 and 36. The staff rotas are well organised and reflect the daily routines of the home. The staff recruitment procedure must be improved. EVIDENCE: The current staff numbers are adequate to meet the needs of the service users and the staff rota is organised to meet their needs. This allows them opportunity to undertake a good range of activities. The rotas are very flexible and are often changed to allow staff to organise activities at fairly short notice. The staff recruitment file for the last member of staff employed was checked and included all the information required. The records for a prospective member of staff was also checked. The manager was awaiting the return of the CRB check and an outstanding reference. However it was noted that the reference was not available from the last employer, which left a gap in the confirmation of employment. This was brought to the manager’s attention whoagreed to seek an additional reference. A new staff induction format has been produced following the last inspection. This is more detailed than the previous one and is signed on completion by the new employee and the mentor. The staff team have been enrolled on the Learning Disability Award Framework (LDAF) and a number of staff are undertaking National Vocational Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 19 Qualifications (NVQ) at different levels. Two of the team leaders are undertaking NVQ level 4. During conversations with members of staff they confirmed they felt the level of training offered allowed them to develop the skills required to help meet the needs of the service users. Staff receive one to one supervision and are involved in the house meetings. They felt they were able to contribute to the decision making process and raise suggestions for improving the service. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 40 and 42. The views of residents and staff are included in the decision making process. The recording of fire safety training must be improved. EVIDENCE: During conversations with the service users it was evident that they were involved in the decision making process and felt they had a say in how the home operates. They were happy to help with the daily tasks and felt the work was allocated in a fair and even way. They were aware of who their key worker was and were included in the regular reviews. To date there is no formal quality monitoring system for the home, however this is planned to be introduced in the near future. Personal allowance is held for all service users. Records are kept of any income, expenditure and the balance held. A spot check was undertaken for one service user and this was recorded correctly. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 21 The home undertakes the weekly fire safety checks and now provides fire safety training for staff. However the manager must include the names of the staff present during the training. This will allow him to be sure that all staff have received training. Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 2 X 3 3 X 2 X Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 23 Are there any outstanding requirements from the last inspection? No 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. Standard YA1 YA6 Regulation Reg 5 Reg 15 Requirement The service user guide must be available in a more user-friendly format. The service user plan must be produced in a format, which reflects the wishes and aspirations of service users. It should be produced in a more user-friendly format. The administration records must include the number of tablets and a start date for all medication. The complaints procedure must be produced in a more userfriendly format. A system for recording complaints must be available. Adult protection training must be provided for all staff. A reference must be sought from the last employer and any gaps in the work history investigated. The manager must complete and return the Manager’s registration application form. The accident recording form must be changed to one that allows staff to record more DS0000064324.V284451.R01.S.doc Timescale for action 01/06/06 01/06/06 3. YA20 Reg 13(2) 01/04/06 4. YA22 Reg 22 01/06/06 5. 6. YA23 YA34 Reg 13 Reg 19 01/06/06 01/04/06 7. 8. YA37 YA42 Reg 9 Reg 17 01/04/06 01/05/06 Hawkstone House Version 5.1 Page 24 detail. 9. YA42 Reg 13(4) The names of the staff attending the fire safety training must be recorded. 01/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 25 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Hawkstone House DS0000064324.V284451.R01.S.doc Version 5.1 Page 26 - 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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