Inspection on 02/08/07 for Healy House (Burnley)

This inspection was carried out on 2nd August 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 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Healy House (Burnley) 12/03/08

Healy House (Burnley) 14/12/06

Healy House (Burnley) 16/05/06

Healy House (Burnley) 24/11/05

Healy House (Burnley) 04/05/05

Healy House (Burnley) 14/12/04

Healy House (Burnley) 28/07/04

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

CARE HOME ADULTS 18-65 Healy House (Burnley) 11 Ormerod Road Burnley Lancashire BB11 2RU Lead Inspector Mr Jeff Pearson Unannounced Inspection 2nd August 2007 09:45 Healy House (Burnley) DS0000009528.V338622.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 Healy House (Burnley) DS0000009528.V338622.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. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Healy House (Burnley) Address 11 Ormerod Road Burnley Lancashire BB11 2RU 01282 838845 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) Mrs Bridget Mary Healy vacant post Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31/05/07 Brief Description of the Service: Healy House is part of Healy Care Burnley, which includes three separate terraced properties. The properties are situated on the same road, in what is primarily a residential area. The home is close to shops and local resources. The accommodation available is homely and mostly domestic in style. The home has a dining kitchen and a communal lounge. There is one shared and three single bedrooms; one of the single rooms has an en-suite facility. There is a large yard to the rear of the home. Staff are on duty to provide support 24 hours per day. Transport is available to enable service users to visit relatives, take short trips, including outings within the local area and further a field. At the time of this inspection visit, the range of fees charged were between £380 and £875 per week, there were voluntary optional charges for entertainment and transport. Information about the services provided is usually available in the home. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Healy House on the 2nd August 2007. The visit took 7¼ hours and was carried out over one day by one inspector. Random unannounced inspections had previously been carried out at the home on 31/05/07 and 13/02/07. Letters following these inspections will be made available on request from the Commission, to members of the public or other enquirers. The files/records of three people using the service were examined as part of ‘case tracking’, this being a method of focusing upon a representative group of people living at the home. Discussion took place with residents, acting manager, staff and the registered provider (owner). Various documents, including policies, procedures and records were looked at. Some of the accommodation and facilities were viewed. At the time of this inspection visit there were 5 people living in the home. What the service does well: People living at Healy House were being involved with some day-to-day matters. House meetings were still being held each week, so people could voice their opinions and be asked about things which affected them. One person explained, “Meetings are held every week to discuss the menus holidays and likes and dislikes and any other comments” Everyone was happy with the meals provided, people were involved with choosing menus and cooking. People were being given opportunity to get out into the local community and join in different activities. One person said they had been out shopping and had their haircut; another had been growing flowers and vegetables in the back yard. One said “I enjoy going out for a swim, it keeps me fit” Some people had been supported to go abroad paid for by the home owner, this had Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 6 been very much appreciated, “we all enjoyed our holiday in Spain, we had a wonderful time it was great” commented one person. Contact with relatives and friends was good, people said they were keeping in touch with their parents and children. People were having some say in who worked at the home, “yes, I helped with the staff interviews” explained one person. What has improved since the last inspection? What they could do better: Following the last inspection, the Commission had taken legal action to require improvements to the inside and outside of the home, within a set timescale. This inspection showed some progress had been made in improving the service at the home. But, there were still outstanding requirements and recommendations from previous inspections. The homeowner therefore again needed to take action to improve matters at Healy House, for the benefit of people using the service. To promote service users rights to information, potential and current service users must each be provided with an up to date, clear, accurate guide to the home, which includes all the proper details. To show service users have been properly assessed and that they are suitable for the home, also to make sure staff are aware of their needs and abilities, their assessment information must be available in the home. Individual care plans still needed to include full details of all their health, behavioural and emotional needs and how they are to be met, to ensure staff know exactly what to do for each person. Individual risk taking was not being properly assessed and staff were not being given clear instructions on how to reduce or manage some risks. Improvements were needed with medication practises and records, to make sure people get their medication safely and at the right time. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 7 Even though some things had improved, the home still needed attention inside and outside, to provide people living there with a satisfactory standard of accommodation To make sure managers and staff do the right thing to make sure people are properly protected, the instructions for dealing allegations, incidents and suspicions of abuse needed changing. The procedure for making complaints needed to be clearer, so that people know exactly how to raise concerns and what will happen if they do. To show staff were being properly recruited and checked out before stating work at the home, recruitment records needed to be available. To make sure the home is properly managed, a lead person, who is trained and responsible, should be on duty at all times. To make sure staff have the right skills and abilities, training and development will need to be ongoing. A manager must register with the Commission, to take legal responsibility for the day-to-day running of the home. To show how improvements are to be made at the home, the owner needed to complete and send to the Commission a quality assurance assessment. Records needed to be available to show things in Healy House were being serviced and checked for the safety of people living in the home. 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. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 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 Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2. Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. Written information about the service provided remained insufficient, which limited peoples’ rights to make informed choices. EVIDENCE: The statement of purpose was not readily available in the home. The Commission was aware that this document had been reviewed and amended on a number of occasions however; there were still a number of additions needed in the information in order that this document meets with the requirements of the Care Homes Regulations 2001. The registered provider was required to ensure the document includes all requirements of the Care Homes Regulations, with a copy being forwarded to the Commission by 31st July 2007. This requirement had not been complied with. The service user guide was available in the home, this also had been revised and updated ion a number of occasions however, there were still a number of additions needed in the information provided in order that this document meets with the requirements of the Care Homes Regulations 2001. The registered provider was required to ensure the guide includes all requirements Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 10 of the Care Homes Regulations, with a copy being forwarded to the Commission by 31st July 2007. This requirement had not been complied with. The acting manager was unaware of any progress made to update the service user guide or statement of purpose. People living at the home said they had not been given a copy of the homes guide. A copy of the he last key inspection report was available in the homes lounge. There had not been any new admissions to the home since the last inspection; however, the initial assessment information in respect of the newest person to move into the home was still not available. The acting manager said she had requested this information from Mary Healy, registered provider and was still awaiting the assessment details to assist with the care planning process. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 11 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): Quality in this outcome area is adequate 6,7,9 This judgement has been made using available evidence including a visit to this service. A lack of good care planning and effective management of risks; meant that people using the service were not always being properly and safely supported. EVIDENCE: Care plans were available for each person living at the home however, there had been no changes to care plans since the last inspection when a requirement was made to ensure plans must included all identified needs and provide clear detailed instructions for staff, on how to meet these needs by 31st July 2007. Although support plans seen included some useful information, they were still lacking in finding out about peoples’ needs, explaining details of their needs and in providing the actions for staff to follow to meet needs. For example, mental health needs had not been properly identified and instructions for responding to specific behavioural needs had not been clearly noted, or they were vague, the plans had not been updated when Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 12 peoples’ needs changed. It was apparent one persons’ care plan had not been updated following a CPA (Care Programme Approach) review. Observation of support practices showed people were being enabled to make some choices and decisions in their daily lives. People had signed in agreement with their plans, but the plans lacked detail and there was no clear evidence to show they were being used in a meaningful way, limitations had not always been properly agreed and managed, staff were not always reflecting upon identified needs and goals in care notes. A requirement was made at the last inspection; to ensure appropriate risk assessments are in place and clear directions given to staff in responding to risk situations. Although some work had been carried out to review risks, there were still significant concerns regarding the lack of appropriate detailed assessment of risks, and the strategies for staff to follow, for example, in response to aggressive behaviour, alcohol and smoking. This meant service users may be at risk from poor management of their and others support needs. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 13 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): 12,13,14,15,16,17 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. People had opportunity to take part in community activities and keep in touch with families. The catering arrangements provided for peoples’ tastes, diet and skill development. EVIDENCE: Four of the people living at the home had recently been on a holiday to Spain with staff support; the registered provider had paid for the holiday. Those spoken with said they had very much enjoyed their time away. During the inspection visit, people living at the home went out into the local community, some with staff support. They spoke of the various activities, both in and out of the home, including day centres, pubs, shops, church, sports/fitness centres, shopping, games and gardening. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 14 People spoken with said they were keeping in touch with members of their families and friends, by telephone, letters and visits. It was apparent from discussion with people living at Healy House and observation of support practices, that independence living skills were being encouraged. One person explained how they were involved with shopping, laundry and cooking. Another had a clear awareness of the house rules. The value of ensuring daily living activities are properly reflected in care plans and support practices; was discussed with the acting manager. House meetings were being held weekly to discuss meals, menus, activities and outings. The value of using meetings to inform people of their rights and the homes policies and procedures and anything that involve them, was discussed with the acting manager. Records showed various meals were being provided to suite individual tastes, diets and preferences. Meals were provided at various times to fit in with peoples’ living patterns. People made drinks and snacks for themselves and said they could get involved with shopping and cooking. Those spoken with said they were happy with the food available and confirmed that menus were agreed each week. The acting manager said sufficient money was provided for catering and shopping. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 15 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): 18,19,20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Not all arrangements and practices were satisfactory in monitoring and responding to health care needs. EVIDENCE: People spoken with said they did not need much support with personal care. Some prompting of personal hygiene practices had been included in care plans. It was apparent from discussion and observation; people were generally being supported to take an interest in their appearance, hairdressing and clothing. Routines of daily life were flexible and people were able to make decisions about their lives, including what time they got up and went to bed, some aspects of daily living needed to be better reflected and agreed in individual care plans. The acting manager said that a health check assessment had been introduced for each person; these were seen to have been completed. Records showed contact with health care professionals such as GPs and CPNs (Community Psychiatric Nurses). People spoken with confirmed they had access to various Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 16 health care professionals, including opticians and dentists. Support was being given to attend hospital appointments. Individual care plans included some details of health care needs, the importance of making sure health care needs are properly highlighted in care plans, to ensure continuity of care was discussed with the acting manager. Medication storage facilities were satisfactory. Individual assessments had been completed with residents on their ability to manage their medication and signed consent forms were seen agreeing to staff support. Medication management policies and procedures were available. There was a gap on one medication administration records with no explanation given; the acting manager was to pursue this matter. Instructions for applying medicated cream still did not specify ‘where’ it was to be applied. There were no individual protocols on giving ‘when required’ medication. A record was not being kept of the administration of a prescribed food supplement. The acting manager said that a system for auditing medication practices was yet to be introduced. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 17 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Not all procedures and practices were effective in supporting the complaints process, or promoting the protection of the people using the service. EVIDENCE: The complaints procedure was on display in the entrance hallway and copies had been placed in each person’s bedroom. The procedure was also included in the service user guide. The procedure on display did not include the contact details of the Commission or other agencies who may provide support. The procedure did not specifically tell people how to make a complaint, or explain the complaints process, stating – “If you are unhappy about anything please tell us so that we can do something about it for you” Systems were in place for records to be kept of complaints made and action taken. One person indicated they did not always feel it was easy to make complaints at the home. Some of the details in the protection policy remained unclear and contradictory. For example, the policy stated “all reports of abuse, no matter how minor, should be immediately be investigated and acted upon by the person in charge…..It is the responsibility of the manager to ensure all accusations are followed through and investigated with or without consent of the person. All cases should be referred to social services without delay.” However, the policy then goes on to explain the action to be taken in the absence of consent, or of none involvement by social services or the police, in Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 18 “line with the victims wishes”. Also, the over- emphasis in the policy of ‘investigating’ reports of abuse; raised questions on the appropriateness of exploring such matters, as apposed to obtaining basic details to then refer to the appropriate agencies for their attention. A requirement had been made at the last inspection to appropriately amend the safeguarding procedures by 31st July 2007. The acting manager said she had undertaken Protection Of Vulnerable Adults training and that arrangements had been made for all staff to receive training, this was to be a distance learning training package provided at he home. It was advised all staff be made aware of the appropriate action to be taken in response to any allegations, incidents and suspicions of abuse. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 19 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Some improvements had been made to provide a more pleasant and homely environment for the people using the service. EVIDENCE: Following the last inspection, an enforcement notice had been served under the provision of the Care Homes regulations 2001, requiring a number of improvements to the environment by 30th September 2007. At the time of the inspection visit, works were ongoing to improve the accommodation. The rear of the home was being sandblasted, some windows had been replaced and the front door had been painted. The ‘office style’ panels and fluorescent lights had been removed from the lounge, the room had been partially decorated and a new carpet fitted. People spoken with very much appreciated Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 20 these improvements and were seen to make better use of the lounge. The walls in the stairway had been painted. Action was being taken to upgrade the shared bedroom, however, some matters were still in need of attention, the ceiling paper had holes where fluorescent lighting strips had been removed, the carpet was stained and holes caused by cigarettes, a large black mark covered half the top of a bedside cabinet. The home was found to be generally clean; the laundry facilities were satisfactory. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 21 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 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Not all staffing arrangements were beneficial to the people using the service. EVIDENCE: There had again been some changes in staff in the staff team, people spoken with expressed concern that “staff were always changing” The staff rota showed appropriate staffing levels were in place and sufficient numbers staff were on duty on the day the home was visited. Staff spoken with, considered staffing levels to be satisfactory in providing support for the people using the service. However, there was no manager on duty and the person in charge did not have proper delegated responsibility for managing the home. The registered person was contacted and arrangements were made for the acting manager who was on leave, to come into work. Records showed staff from another home had been called to provide support with a specific incident, which may have had impacted upon the staffing arrangements in that home. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 22 Positive interactions were observed between the service users and staff. People spoken with were generally appreciative of the support provided by the staff team. Two new support workers had been recruited to work at Healy House and other homes in the organisation. The recruitment records of the new employees were not readily available in the home; therefore the registered provider was unable to show that appropriate checks had been carried out for the protection of the people using the service. People spoken with confirmed their involvement in selecting staff to work in their home. The induction training records of one of the new employees were seen, it was apparent training was ongoing. The induction training records of the other new employee were unable to be located, however the staff member spoken with indicated some training had been given. Records showed neither of the new staff members had read and signed the fire record book, which included basic fire training. Three support staff including the acting manager had attained NVQ (National Vocational Qualifications) level 3; two support staff had NVQ level 2. One member of staff was currently undertaking NVQ level 2 another NVQ level 3. The acting manager said she was to re-commence the Registered Managers Award in September. Not all staff had received training in mental health issues. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 23 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): Quality in this outcome area is poor This judgement has been made using available evidence including a visit to this service. People living in the home did not benefit from consistent, effective leadership and management of the service. EVIDENCE: The Commission for Social Care Inspection has serious concerns regarding the operation and management of Healy House. There is evidence of historical erratic performance at the home which has lead to a lack of sustained improvement over time. This inspection visit showed that a number of requirements had not been addressed and therefore action to address these areas remained outstanding. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 24 Since the last key inspection another acting manager had been appointed at Healy House. There have been several acting un-registered managers who have stayed at Healy house for varying lengths of time. Although some improvements had been made, evidence included within this report indicates shortfalls in relation to the management and daily running of the home. There has been a long standing requirement for a manager to be appointed at the home and to be registered with the Commission for Social Care inspection. At the last inspection a requirement was made for a suitable manager to apply for registration with the Commission by 30th September 2007, the acting manager said she was in the process of completing the application. The AQAA (Annual Quality Assurance Assessment) had not been completed and returned to the Commission prior to the inspection visit, and was not made available during the inspection. It is a legal requirement to complete and return this assessment to the Commission, to provide information about the service and plans for improvements. House meetings provided some opportunity for people living at the home to be consulted and voice their opinions. The acting manager said quality surveys had recently been given to people living in the home and staff. Previous inspection reports have identified significant matters for improvement; these have not been implemented within agreed timescales. Documentation was not readily available to show that installations and equipment, such as electrical wiring and gas appliances had been serviced. Records showed fire drills and fire equipment tests were being carried out. However, fire risk assessments were not available in the home. General health and safety risk assessments had been carried out; it was advised these be linked in with the maintence records as appropriate. The training matrix indicated some progress had been made in ensuring all staff receive training in safe working practices, the importance of ensuring this continues was discussed with the acting manager. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 25 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 1 2 1 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 2 23 1 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 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 2 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 1 X 2 X X 2 X Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 26 Yes 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 YA1 Regulation 4,5,6 Requirement To promote people’s rights and choices, the statement of purpose and service user guide must include clear factual information about the services and facilities provided. A copy of the revised service user guide must be given to each service user (Timescales of 08/07/05, 30/06/06, 14/12/06,13/02/07 and 31/07/07 not fully met) A copy of the guide must also be forwarded to the Commission. To show people have been properly assessed and to promote good care planning, records of service users initial assessment must be kept available in the home. (Timescales of 03/02/05 and 30/06/06, 14/12/06, 13/02/07 and 31/07/07 not fully met) To make sure people receive proper care and support, service users plans must include all identified needs and DS0000009528.V338622.R01.S.doc Timescale for action 30/09/07 2. YA2 14,17 30/09/07 3. YA6 15 30/09/07 Healy House (Burnley) Version 5.2 Page 27 4. YA9 13 5. YA9 13 6. YA23 13 7. YA24 16,23 8. YA34 19 9. YA37 8 provide clear detailed instructions for staff, on how to meet these needs. (Timescales of 31/03/07 and 31/07/07 not met) To make sure a reasonable balance is achieved between independence and personal safety, risk assessments/risk management strategies must be completed on service users engaging in activities, which may affect their health or wellbeing. (Timescales of 30/06/06, 02/03/07 and 31/07/07 not met) To make sure people are supported as safely as possible, risk assessments/risk management strategies must be completed in response to service users behavioural needs. (Timescales of 31/03/07 and 31/07/07 not met) The Safeguarding adults Procedure needs amending to ensure that staff have clear directions of the actions they should take should a suspicion, incident, or allegation of abuse come to their attention. Timescale of 31/07/07 not met. To provide people with a comfortable and safe home, the areas of concern highlighted in the body of this report relating to the environment must be addressed. To show new employees are being properly recruited and checked, appropriate staff recruitment records must always be available for inspection. To make sure the home is effectively managed, a suitable manager must apply for registration with the DS0000009528.V338622.R01.S.doc 30/09/07 30/09/07 30/09/07 30/09/07 30/09/07 30/09/07 Healy House (Burnley) Version 5.2 Page 28 10. YA39 24 Commission (Timescales of 10/02/06, 31/07/06 and 31/03/07 not met) To show how improvements are 30/09/07 to be made at the home, the registered person must complete and return to the Commission, the Annual Quality assurance Assessment. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA6 YA7 YA20 Good Practice Recommendations Service user Plans should be reviewed and updated at least six monthly, or more frequently if required. To promote better review systems good care planning, care notes should reflect upon goals achieved and needs met. To ensure people are properly and safely supported with their medication• Systems should be set up in the home to audit the control of medicines. • The medication administration records should clear specify ‘where’ topical preparations are to be applied. • Clear criteria should be defined on an individual basis, when service users are prescribed when necessary and variable dose medication. • Records should be kept of the administration of prescribed food supplements. To ensure peoples’ rights to raise concerns are promoted and supported, the complaints procedure should more clearly specify the process for making complaints. To ensure people are properly supported, staffing arrangements should ensure a member of staff is always on duty to manage the home. On call systems should not rely upon staff working in other homes in the organisation. The programme of staff training and development needs to continue, to ensure staff are able to respond to the service users needs. To show new staff are being properly trained, induction DS0000009528.V338622.R01.S.doc Version 5.2 Page 29 4. 5. YA22 YA33 6. 7. YA35 YA35 Healy House (Burnley) 8. 9. 10. YA35 YA39 YA42 training records should be readily available in the home. All support staff should be enabled to undertake appropriate mental health training. The quality assurance system needs to ensure all relevant people are consulted and that a development/action plan is produced. Documentation to show the servicing of equipment and appliances should be readily available in the home. Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 Healy House (Burnley) DS0000009528.V338622.R01.S.doc Version 5.2 Page 31 - 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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