Inspection on 14/11/05 for Hawthorn Street

This inspection was carried out on 14th November 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hawthorn Street 19/10/06

Hawthorn Street 01/02/06

Hawthorn Street 30/03/05

Hawthorn Street 12/01/05

Hawthorn Street 29/03/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Hawthorn Street 2-4 Hawthorn Street Amisfield Road Hipperholme Halifax West Yorkshire HX3 8NZ Lead Inspector Lynda Jones Unannounced Inspection 14th November 2005 10:15a Hawthorn Street DS0000001053.V265877.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 Hawthorn Street DS0000001053.V265877.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. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hawthorn Street Address 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) 2-4 Hawthorn Street Amisfield Road Hipperholme Halifax West Yorkshire HX3 8NZ 01422 203541 St Anne`s Community Services Mr Gerard Wainwright Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th March 2005 Brief Description of the Service: Hawthorn Street is a care home that is registered to provide care and support for seven adults with physical and learning disabilities. The home is owned and managed by St Anne’s Shelter and Housing Action. The home is in the Hipperholme area of Halifax. Local shops, a church, pub and other local amenities are within walking distance. The home can be easily accessed by public transport. Accommodation is provided in two semi detached houses. There is internal access to both houses at ground and first floor level. Large living and dining areas are provided in each house. All of the bedrooms are single; toilet and bathing facilities are located close to the bedrooms. The houses are surrounded by well-maintained, enclosed gardens. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by two inspectors over 2.5 hours. Staff records, medication records, service user plans and personal money records were examined. Discussion took place with the manager who was on duty. What the service does well: What has improved since the last inspection? What they could do better: Staff should use one system for recording the progress made by service users towards meeting personal objectives. This should make it much easier to see what progress service users are making. It would be useful to record details of service users’ preferred routines, methods of communication and support needs, rather than pass this information on verbally within the staff team. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 6 Plans must be in place for every service user. The initial assessment should form the basis of the service user plan. The plan should include individualised procedures for service users who present challenging behaviour. 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. Hawthorn Street DS0000001053.V265877.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 Hawthorn Street DS0000001053.V265877.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): 1,2,4,5. Introductions to the home are well planned and allow ample time for service users to sample the accommodation and meet other people. EVIDENCE: The same group of men have lived at Hawthorn Street since it was first registered in March 1993. There was one vacancy at the home from April 2003 up to May 2005. Between March and May 2005 a prospective occupant began visiting the home to see if it would be suitable for him to move in and whether it could meet his needs. Evidence shows that some good preparatory work was undertaken before the visits commenced. The visits were intended to ascertain whether the home suited the prospective service user and to establish whether the home could meet his specific needs. The visits were planned in advance and the time spent at Hawthorn Street was gradually increased from short visits to overnight stays. He eventually took up residence in May 2005. Everyone living at the home has a contract and license agreement outlining their terms and conditions of residence. Hawthorn Street DS0000001053.V265877.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): 6,7,9 Staff should use one system for recording the progress made by service users towards meeting personal objectives. This should make it much easier to see what progress service users are making. EVIDENCE: Person centred plans are used at the home. The records show that the plans contain a series of objectives that each individual is working towards, these include taking part in various activities and improving skills within the home. On previous inspections it was noted that when a specific activity took place, this was recorded on a weekly monitoring sheet, this information was then used by the manager to carry out a monthly check on the progress made towards meeting the objectives. On this inspection it was noted that the weekly sheets were not always used. Inspectors were informed that some staff recorded details of specific activities in with the daily records, while others continued to use the weekly sheets. Using both approaches is not helpful. The staff team need to decide which method allows the most effective evaluation of progress. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 10 From evidence on the weekly sheets it seems that some people have made very little progress towards achieving their personal objectives, although this may be due to the mixed methods of recording. For example, one person was to go to the library to choose a selection of CD’s to listen to. The records suggest that this activity had taken place only three times since October 2004. Another objective was to go swimming once a week, records suggest that this had not taken place since June 2005. On another plan inspectors noted one service user wanted to take regular exercise and was to be accompanied on a walk two times each week. According to the monitoring sheets this had not taken place since May 2005. In order to carry out a detailed monthly evaluation of progress towards objectives it would be necessary to trawl through the often-lengthy daily records to extract information. Inspectors felt that this would be a time consuming exercise, which could be better managed. Inspectors felt that service users had a right to expect that objectives such as “to receive consistent support with daily routines” were part of the service provided and not personal goals. It was disappointing to note that there was no plan in respect of one person who had lived at the home for six months. The manager reported that a planning meeting was scheduled for the coming week. Inspectors asked to see the information that had been prepared for the meeting, including an evaluation of the past months. No written information was available. The risk assessment in respect of this individual was from June 2004 and had been carried out before he moved to Hawthorn Street. Additional information relating to meal times had been added but had not been dated. The plans should include individualised procedures for service users who may present challenging behaviour. Inspectors expressed great concern about the way in which a recent incident involving one service user had been managed. The incident involved calling the police to the home. This was discussed with the manager during the inspection and subsequently with the Area Manager. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 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, 15,16. Service users have the opportunity to take part in various leisure activities and are enabled to pursue personal interests and hobbies. EVIDENCE: There is evidence that all service users go out regularly and take part in a range of leisure activities. From discussion with the manager it is clear that individuals are encouraged and supported to pursue their own interests and hobbies. On the day of inspection, two people went out with staff to do some of the household shopping, later in the day two people were going out for a walk with staff. The records show that everyone has the opportunity to go on days out and holidays of their choice. The manager said that service users were supported to keep in touch with their families and friends and visits from relatives were welcomed. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,20 Insufficient information is recorded about the way service users prefer their personal care to be delivered and about their preferred daily routines. Medication records are well maintained. EVIDENCE: It is not possible to tell from the written records how service users like to receive personal support. The staff rely on their knowledge of individuals and on their verbal communications with each other. It is unlikely to happen, but if all the staff team were unable to work, there is nothing written down which would enable replacement staff to understand service users preferred routines, methods of communication, personal care and support needs. Medication records were checked and were found to be satisfactory. Good practice was noted in recording information about how each service user prefers to take their medication eg. on a spoon, with milk etc. There are guidelines regarding the use of PRN (as required) medication. Inspectors felt that these could contain more detail. This was discussed at the time of the inspection. It was not clear how often people were weighed. Records suggest that this should be done monthly but this does not happen in practice. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23. The home has appropriate systems in place to ensure that service users are safeguarded from abuse and that complaints are dealt with promptly. EVIDENCE: A detailed complaints procedure is in place. No complaints have been made. Records of money held on behalf of service users were examined. One minor arithmetical error was noted but otherwise the records were in good order. Staff need to ensure that inventories of personal possessions are updated as service users purchase new items of furniture etc for their bedrooms. The manager needs to check that all staff have undertaken adult protection training. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were assessed on this inspection. EVIDENCE: Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34,35. There is a robust recruitment process and detailed checks are carried out before new staff start work at the home. A range of training is available to all staff. EVIDENCE: St Anne’s operates a thorough recruitment process. References are always taken up and CRB checks are carried out for all new staff before employment commences. All staff undertake a range of statutory training. The training records at the home are good, there is a useful matrix that shows what training has taken place and when training updates are required. Regular staff supervision and annual appraisals take place. The records show that training needs are identified through staff supervision. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,43 The home is well managed. The views of service users, relatives and staff are valued. EVIDENCE: The manager is a qualified nurse with several years experience of working with people with learning disabilities. He has worked in various homes managed by St Anne’s in the Calderdale area over the past twelve years, providing care and support for people with learning disabilities, complex health care needs and challenging behaviours. He moved to this post in September 2004 from a senior post in another St Anne’s home. He was registered by CSCI as the manager of Hawthorn Street in May 2005. The manager is available at the home on most weekdays; he encourages an atmosphere of openness and respect and is willing to listen to the opinions of others. Service users, their relatives and staff are encouraged to comment on the way the home is run and to voice any concerns they might have about the service. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 17 The registered manager has recently been overseeing the management of another nearby St Anne’s home in addition to his usual duties. This arrangement has now ceased and since October 2005 he has returned to his position and is now able to devote his time and attention to the management of Hawthorn Street. This will be of considerable benefit to service users and to the staff team. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 1 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hawthorn Street Score 2 X 3 X Standard No 37 38 39 40 41 42 43 Score 3 3 X X X X 3 DS0000001053.V265877.R01.S.doc Version 5.0 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA6 YA6 Regulation 15 12 Requirement A plan must be in place in respect of every service user living at the home. Plans must include individualised procedures for service users who present challenging behaviour. Timescale for action 31/12/05 31/01/05 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 Refer to Standard YA6 YA6 Good Practice Recommendations One system should be used to record the progress made by service users towards meeting personal objectives. Details of service users preferred routines; methods of communication and support needs should be recorded. Hawthorn Street DS0000001053.V265877.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Hawthorn Street DS0000001053.V265877.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. 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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