Inspection on 10/07/07 for Headingley Court

This inspection was carried out on 10th July 2007.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 18 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Headingley Court Headingley Way Edlington Doncaster South Yorkshire DN12 1SB Lead Inspector Sarah Powell Key Unannounced Inspection 10th July 2007 09:20 DS0000070013.V347558.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address DS0000070013.V347558.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. DS0000070013.V347558.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Headingley Court Address Headingley Way Edlington Doncaster South Yorkshire DN12 1SB 01709 866610 01709 866611 headingley@mimosahealthcare.com 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) Mimosa Healthcare Group Limited Post Vacant Care Home 25 Category(ies) of Physical disability (25) registration, with number of places DS0000070013.V347558.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two named service users over the age of 65 are able to stay at Headingley Court while their needs can be met. If their needs change and the home is no longer able to meet their needs this condition will be removed. no longer able to meet their needs this condition will be removed. One specific service user with a physical disabiIity and associated learning disability named on variation dated 29 October 2004 may reside at the home One specific service user over the age of 65, named on variation dated 6th December 2004, may reside at the home. Service Users with a physical disability and an associated learning disability are able to live at Headinglety Court and remain while their needs can be met. 30th January 2007 2. 3. 4. Date of last inspection Brief Description of the Service: Headingley Court is a single storey modern building in Edlington village close to local shops and amenities. The home is purpose built, providing accommodation for adults with physical disabilities. The people living at Headingley Court have many varying conditions. The home has been adapted accordingly, with ramps and wide corridors for easy access. The home is surrounded by pleasant well-maintained gardens and has a large car park. The fees at Headingley Court were £490 - £1006 for further information contact the home. DS0000070013.V347558.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection and took place over one day. The inspection was on 10th July 2007 at 09:20 and finished at 16:30. As part of the inspection process the inspector spoke to 8 people who lived at the home, 5 staff, 3 relatives, the new manager and the managing director. Five residents questionnaires were also returned. During the inspection a tour of the building took place, observing the environment, staff and care practices. A number of records were examined these included care plans, staff rotas, recruitment, maintenance records and quality assurance systems. Feedback was given to the new manager and the managing director at the end of the visit. What the service does well: What has improved since the last inspection? The new manager had only been in post a month at the time of the site visit, however it was clear that some improvements had been made. Staff morale had improved, staff said, “it is a different style of management but a good one and we should have a good working relationship”. The dining room and old smoke room had been redecorated to a high standard and new floor covering had been laid. The old smoke room had been made into an activities/games room, which was well used by the people living at the home. The standard of cleanliness observed during the visit had much improved and relatives commented that the home was very clean and much improved from a few months ago. DS0000070013.V347558.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. DS0000070013.V347558.R01.S.doc Version 5.2 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 DS0000070013.V347558.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The assessments clearly identified people’s needs to be able to determine if they could be met. EVIDENCE: Two people were case tracked as part of the inspection process and full assessments were seen in their plans. The assessments clearly identified the needs of the person and helped determine that the home could meet these needs. For people referred through care management, there were assessments in the files carried out by the social worker from the placing authority. DS0000070013.V347558.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Care plans had identified needs, however more evidence was required on how people were supported to make decisions and how they were supported to take risks. EVIDENCE: Two peoples care plans were looked at as part of the case tracking. The plans had not been improved since the last inspection and many had not been reviewed. However the new manager was aware that the care plans needed some attention and this was to be addressed. The life history and pen picture in each plan was very good, gave good detail of the person and helped staff understand the needs of each individual. DS0000070013.V347558.R01.S.doc Version 5.2 Page 10 The risk assessments were better but still did not clearly identify risks or give good information on how to reduce or manage the risks, potentially placing service users at risk of harm or injury. People who lived in the home said, “we are able to make decisions although we are not always able to do the things we want it depends what staff are on duty and how busy they are”. However when asked by the inspector if things were improving they said, “ things have improved in the last few weeks, and I think they will continue to improve”. DS0000070013.V347558.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The activities for the people in the home had improved. Meals were of a good quality but hectic and did not meet all people’s needs. People’s rights were not always respected. EVIDENCE: Activities for people who lived in the home had greatly improved. Many peoples attended day centres on various days of the week, two people received a number of 1 to 1 hours and the activity coordinators hours had been increased to 42 hours per week. The activity coordinators were very enthusiastic and provided good activities suitable for the people who lived in the home. Mostly group activities were still provided however the 1 to 1 DS0000070013.V347558.R01.S.doc Version 5.2 Page 12 activities were improving with the activities co-ordinators more aware of what activities or stimulation needed to be provided to meet peoples needs. The people said, “the activities have improved and we look forward to them”. They also said there were more outings to the pub, local shops and clubs. Five people went out on the day of the inspection for lunch, which they thoroughly enjoyed. When the activity co-ordinators were not working people were still placed in the lounge in front of the television with no other stimulation and many were still put to bed in the afternoon. It was not clear if this was their choice, as it was not clearly documented in plans of care. Links with family and friends were encouraged and maintained, visitors spoken to said, “I am able to visit at any time and am able to see my relative/friend in private if I want”. Most staff were observed interacting well with the people living in the home. However some staff were observed giving assistance to people with no communication or explanation as to what they were about to do. Most people had their meal in the lounge and it was not clear if this was their choice of if it was because it made it easier for the staff. There were a lot of people who required assistance with eating, most staff gave this sensitively and respectfully, however one member of staff was observed standing over the person and not interacting with the person causing possible distress to the person who was unable to verbally communicate. The meal was very busy and did not provide a relaxed setting for the people in the home. There were not enough staff to give assistance and many had to wait a long time to be given assistance. People and relatives said, “the meals are always nice and choices are available, but it can be a very busy time and it feels rushed” DS0000070013.V347558.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19. Standard 20 was covered by the pharmacy inspection on 00/05/07 and the outcome for this standard was adequate which showed an improvement. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Personal support was not always flexible and health care needs of the people living in the home were not always met. EVIDENCE: Most personal support was given in the way service users preferred however it was not always flexible due to staff numbers and busy periods. Routines in place were not necessarily the best practice, people were still put to bed in the afternoons as an institutionalised practice and not necessarily the persons choice. Staff said that people were still sometimes restricted to times they were able to have a bath or shower due to staffing numbers. Staff numbers had been decreased to three carers on the morning shift, which did not always meet the needs of the people in the home. DS0000070013.V347558.R01.S.doc Version 5.2 Page 14 Not all health care needs of people were appropriately met. Many issues identified had been referred through the adult protection procedures and had been part of an investigation; many of these investigations were not completed. DS0000070013.V347558.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The homes complaints procedure was good and the adult protection policies were good, however the home had not always protected people from abuse. EVIDENCE: There was a good complaints procedure that was displayed in the entrance area and this gave clearly defined timescale for action. The home had received four complaints since the last inspection. Three were resolved and partially upheld by the provider who investigated the complaints. One complaint was still being investigated through the adult protection procedure. The adult protection investigation regarding the needs of people with a learning difficulty was still ongoing from 2006. A further five referrals had been received between November 2006 and January 2007. one further referral had been received in February 2007 which has been investigated by an investigating officer appointed by Doncaster Council. The home also did some disiplinary action regarding this referral and it has been resolved and awaiting a case conference date so it can be closed. No further referrals had been received and the new manager was orgainising some adult protection training for all staff to ensure the people in the home were protected from abuse. DS0000070013.V347558.R01.S.doc Version 5.2 Page 16 Due to the large number of referrals and concerns regarding the ability of the home to protect people Doncaster Council had placed an embargo on the home preventing any further admissions, this is still in place. DS0000070013.V347558.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standard of cleanliness was good and environmental standards were improving to provide a homely, comfortable environment for the people that lived there. EVIDENCE: A tour of the building was carried out and the standard of cleanliness observed was very good, providing a clean environment for the people who lived there. The domestic hours had been increased and domestic hours were provided at weekends. The manager was reviewing the hours provided for domestic, catering and laundry to further improve this service for the people who lived there. The dining room and old smoke room had been redecorated and new floor covering laid this provided comfortable, homely rooms. The company had gone DS0000070013.V347558.R01.S.doc Version 5.2 Page 18 smoke free in the home from 1st July 2007. Existing people at the home who smoked were allowed to continue if they went outside to an area at the side of the building. This arrangement was fine in the summer but in bad weather this provided no shelter. Many areas requiring improvement identified at the last two inspections had still not been addressed. The floor coverings in bathrooms, toilets and some bedrooms were stained and marked. Wall tiles in some bathrooms and toilets had come off the wall. Wall plaster was damaged in bedrooms. Some taps on sinks and baths were rusting and unable to be turned off properly so constantly dripping. Curtains were not properly fixed in some rooms and did not close properly or were hanging off the rail. The managing director said that the home was again without a maintenance person and this had slowed things down. The empty rooms were nearly completed and then they could move people out of their rooms while they are decorated. One person said, ”I have chosen my new curtains and bedding and they have been ordered”. DS0000070013.V347558.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35. People who use the service experience poor quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Mandatory training was out of date and people’s needs were not always appropriately met. The staff team did not always meet people’s needs. Recruitment procedures were robust protecting people who lived at the home. EVIDENCE: Staff did not have all the required competencies and qualifications to meet people’s needs. A training programme was in place but the majority of staff had not attended the mandatory training and this was still out of date. NVQ training was to be recommenced for care staff to ensure staff were competent and qualified to meet the need of the people in the home. The staffing numbers had been reduced this did not provide an adequate number to meet peoples needs at peak times. Staff said, “It is very busy and rushed at times and difficult to meet all the needs of the people in the home”. DS0000070013.V347558.R01.S.doc Version 5.2 Page 20 Recruitment procedures were good. Files seen contained all the required information including criminal record bureau checks, protecting people who lived in the home. DS0000070013.V347558.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Policies and procedures were in place. The new manager was implementing quality assurance systems. Maintenance records were available, but not all were carried out as often as they should be, to safeguard people in the home. EVIDENCE: There was a new manager in post at the time of the inspection and he was applying to the Commission for Social Care Inspection to become the registered manager. DS0000070013.V347558.R01.S.doc Version 5.2 Page 22 Quality assurance systems were in place to seek the views of people in the home, however the new manager was only just implementing these. Some maintenance records were available at the home but many were not. The managing director assured the inspector that these were carried out and copies of the certificates were kept at head office. The records that the maintenance person usually carried out were being done by the new manager. However these were not being carried out as often as they should have been. Putting people in the home at a possible risk of harm. DS0000070013.V347558.R01.S.doc Version 5.2 Page 23 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 3 3 X 4 X 5 X 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 1 33 X 34 3 35 1 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 2 X LIFESTYLES Standard No Score 11 X 12 2 13 3 14 X 15 3 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 2 X 2 X 2 X X 2 X DS0000070013.V347558.R01.S.doc Version 5.2 Page 24 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 YA35 Regulation 18 Requirement All staff training must be updated to meet the needs of the people in the home (previous timescale 01/03/06, 01/01/07 and 01/05/97). Risk assessments must be in place for all people in the home and they must be supported to take risks as part of an independent lifestyle (previous timescale 01/10/06 and 01/05/07). The daily routines of the home must promote independence and freedom of choice for the people who live there. (previous timescale 01/09/06 and 01/04/07) All people must receive personal support that is flexible to meet their needs (previous timescale 01/09/06 and 01/04/07) Timescale for action 01/09/07 2. YA9 13 01/09/07 3. YA16 12 01/09/07 4. YA18 12 01/09/07 DS0000070013.V347558.R01.S.doc Version 5.2 Page 25 5. YA19 12 All peoples health care needs must be met (previous timescale 0/09/06 and 01/04/07). The company must submit an application to register a Manager with the Commission for Social Care Inspection (previous timescale 01/12/06 and 01/06/07). 01/09/07 6. YA37 8&9 01/09/07 7. YA39 24 Quality-monitoring systems must 01/09/07 be re-commenced to seek views of the people who live in the home and maintain a good service (previous timescale 10/10/06 and 01/05/07). All maintenance records must be available and up to date to protect people who live in the home. (previous timescale 01/05/07). All people in the home must be supported to make decisions and staff must support people to act on those decisions. (Old timescale 01/05/07) Meals must not be rushed and peoples needs must be met and identified if requiring assistance this must be offered in a sensitive manner that protects the persons dignity. (Old timescale 01/05/07) The stained and marked floor coverings in bathrooms, toilets and bedrooms must be replaced providing a good environment for the people who live there. (Old timescale 01/06/07) DS0000070013.V347558.R01.S.doc 8. YA42 12 01/08/07 9. YA7 12 01/09/07 10. YA17 12 01/09/07 11. YA24 23 01/09/07 Version 5.2 Page 26 12. YA24 23 Missing wall tiles in bathrooms and toilets must be replaced. (Old timescale 01/06/07) The damaged wall plaster in bedrooms must be repaired and re-decorated. (Old timescale 01/05/07) The leaking taps at sinks and baths must be replaced. (Old timescale 01/05/07) Suitable curtains and curtain tracks must be provided to all bedrooms. (Old timescale 01/05/07) All people who live in the home must have a plan of care that is regularly reviewed to ensure their needs are met. All people who live in the home must take part in fulfilling activities that meet their needs. All staff must receive training in protection of vulnerable adults in order to understand what this is and safeguard people who live in the home. 01/09/07 13. YA24 23 01/09/07 14. YA24 23 01/09/07 15. YA26 16 01/09/07 16. YA7 15 01/09/07 17. 18. YA12 YA23 16 12 01/09/07 01/08/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA32 Good Practice Recommendations It is recommended that 50 of staff achieve NVQ level 2 or above to meet the needs of the people in the home. DS0000070013.V347558.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI DS0000070013.V347558.R01.S.doc Version 5.2 Page 28 - 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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