Inspection on 21/06/05 for Henderson and Harvard

This inspection was carried out on 21st June 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 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Henderson and Harvard 30/11/06

Henderson and Harvard 05/12/05

Henderson and Harvard 10/11/04

Henderson and Harvard 17/05/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Henderson and Harvard Kelvedon Road Tiptree Colchester Essex C05 0LJ Lead Inspector Ray Burwood Final Unannounced 21 June 2005 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 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 Stationary 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. Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Henderson and Harvard Address Kelvedon Road, Tiptree, Colchester, Essex C05 0LJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01621 819354 01621 819354 SCOPE Ms Sarah Ashman Care Home 8 Category(ies) of Learning disability (8), Learning disability over registration, with number 65 years of age (1), Physical disability (8), of places Physical disability over 65 years of age (1) Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10/11/04 Brief Description of the Service: The home consists of two converted semi-detached bungalows, Henderson and Harvard, located in the town of Tiptree. Each bungalow accommodates four service users who are provided with single bedrooms adapted to meet their individual needs. The home is adapted to meet the needs of service users with physical disabilities. All local facilities and amenities are within easy access. The home has limited parking. The service users benefit from pleasant gardens and patio areas. The space between the two bungalows have been joined and converted to provide a shared laundry area. Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 21st June 2005. The home’s manager, who has recently been registered with the Commission for Social Care Inspection (CSCI), was away from the home on a training course. The registered manager of another locally based SCOPE home, assisted the inspector, together with service users and staff. During the visit the inspector spoke to service users and staff, inspected service users and staff files, and also undertook a tour of both bungalows. A total of 15 standards were inspected with 10 standards being met. The two bungalows provided a caring and comfortable environment in which service users’ were supported individually, and as a group, by staff working in the home. Both groups of service users, with the exception of one service user who was attending a Day Centre, were present at the time of the inspection and commented positively on the standard of care they received. Areas highlighted at the last inspection, in relation to service users access to the garden area, and possible structural changes within Harvard have been surveyed, and estimates submitted to SCOPE’s Head Office for consideration. What the service does well: Henderson and Harvard provide a committed key-work system and good relationships with service users families and professionals that support the service. Staff spoken with during the inspection confirmed that the service provided good training and development opportunities, and regular supervision sessions. This was evidenced in staff files where appropriate records were kept. Four service users spoken to during lunch, spoke of the friendly environment, and they were happy with the overall service they received from the home. Service users healthcare needs are regularly monitored, reviewed and referrals made to appropriate healthcare professionals when necessary. Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? 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. Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 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 standard(s) 2. The home has a comprehensive admission process that clearly links the needs, wishes, and aspirations of prospective service users with the services provided. EVIDENCE: No new service users had been admitted to the home since the new assessment documentation had been developed. These documents included comprehensive healthcare information and living options assessments competed by the social worker and home’s manager. Further assessment documentation was in place for completion during an initial trial period of residency (Care Profile) A summary of this document, included financial arrangements between the service user and the home. Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 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 standard(s) 6 and 7. The service users care plans are comprehensively detailed, appropriate to their needs and well maintained. Service users are enabled to make informed choices and decisions with support from staff. EVIDENCE: The care plans of service users from both bungalows were inspected to give a balanced view of the services being provided. The care plans sampled contained the information required to enable staff to carryout the assessed care needs of service users. Evidence was contained in care plans in relation to service users and/or their representatives, participating in the care planning process. Detailed risk assessments and manual handling assessments were included and gave clear guidelines for staff on actions to be followed in these particular areas of their duties. Plans are reviewed on a regular basis. During the inspection process staff were seen to treat service users with care and respect, and were on hand to provide support when requested. Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 Page 10 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 standard(s) 12,13 and 15. Service users are provided with the opportunities and are assisted in accessing a wide range of educational and recreational activities. Links with families and friends are supported and maintained by the home. EVIDENCE: From discussions with service users and staff it was noted that there were opportunities for service users to engage in a range of activities. These included accessing activities within the organisation, where another home provided structured educational sessions. Activities are also provided both in the home and in the community, they included dance, Art and craft sessions. None of the current service user group was able or wished to take up any form of employment. Service users are able to access, and are involved with the local community by attending the local church, visiting the library and local pubs. Transport to these venues is provided by the home’s mini-bus. Management and staff agreed that service users families and friends were welcome to visit the home if possible, but supported those service users who Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 Page 11 could only correspond with family and friends who lived a long way from the area. Service users are able to meet in private with friends and relatives via their own bedrooms. However, the manager was advised to consider making available an additional room for private visits. (See recommendations). Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 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 standard(s) 19 and 20. Evidence reflected that healthcare needs of service users are managed effectively. The home’s medication systems and procedures ensured the protection and wellbeing of service users. EVIDENCE: Service users healthcare needs are clearly documented in their care plans. Records relating to referrals were supported by appropriate information in terms of why the referral was made and the subsequent outcome. The home had developed a hospital information document to accompany a service user, should they require hospitalising/A&E treatment. The document is divided into three sections, green, amber and red and prioritises certain information pertaining to the individual concerned. The home’s medication system and the policies and procedures included in SCOPE’s A-Z of policies, was in place and seen to meet the standard. Medication is dispensed via the Boots ‘Measured Dosage System’ (MDS). All staff administering medication are appropriately trained Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 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 standard(s) 23. The homes Adult Protection policies and procedures were adequate to help ensure the protection of service users from harm or abuse. EVIDENCE: The home’s Adult Protection policies and procedures (including Whistle Blowing) was used across the organisations homes (SCOPE) and was contained in the A-Z set of policy documents. Policies were comprehensively detailed and provided staff with clear information in line with the Department of Health (DOH) guidelines, ‘No Secrets,’ in recognising and responding to abuse. Staff spoken with confirmed that they had received appropriate training through SCOPE and were aware of the Essex County Council guidelines for reporting incidents of abuse. Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 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 standard(s) 24 and 28. The overall environmental standard of both bungalows are good and offer service users a comfortable and homely place to live. The home should consider remedial work to both Harvard and the garden access as an interim measure. EVIDENCE: The environmental standards at both bungalows are generally good, clean, tidy and free from any offensive odours. Both Henderson and Harvard are homely and decorated to a good level with furnishings suitable to the needs of the service users. Some areas within Harvard are being damaged by wheelchair users, who are restricted from turning. This is currently being addressed by the organisation with a view to possibly changing the internal layout of the home. (See Recommendations) As reported in the home’s previous inspection, service users access from both bungalows to some parts of the garden area, are considered to be unsafe for wheelchair users because of narrow paths that have low walls running alongside. Again, as part of a recent survey carried out, work is planned to address this issue. (See recommendations) Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33 and 34. Staffing numbers and experience are appropriate to the needs of service users. The home’s recruitment process was robust and ensured the protection of service users. EVIDENCE: Since the home’s last inspection, the manager has carried out a recruitment drive to ensure that there is a consistent and more effective staff team supporting service users. During the inspection process evidence was shown that interviews had been completed and checks required by Regulations are currently being undertaken. During this period the home is using experienced agency staff that have supported the home on a regular basis. (See requirements). The files of three members of staff was sampled and inspected. All files contained the required information laid down in Schedule 2. Files contained interview notes, job descriptions, terms and conditions and completed medical surveys. Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42. The manager should continue to progress the home’s quality assurance system in order to improve the service it provides. Records and testing of equipment for the protection of service users are well documented and maintained. EVIDENCE: The manager was in the process of analysing the feedback received from service users, other stakeholder surveys and continues to further develop the home’s quality assurance system. As sample of safety certificates and records of internal checks were viewed and seen to comply with requirements. These included: • • • • Boiler servicing. Electrical installation and Portable Appliance test certificates. Fire alarm, fire equipment and fire training records. Hot water outlet temperature records. I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 Page 17 Henderson and Harvard • • Emergency lighting checks. Up to date servicing records of disability equipment. Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 2 x x Standard No 11 12 13 14 15 16 17 x 3 3 x 2 x x Standard No 31 32 33 34 35 36 Score x x 2 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Henderson and Harvard Score x 3 3 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 Page 19 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 TA33 Regulation 18 (1) (a) Requirement Timescale for action 31/08/05. 2. YA39 24 (10(a)(b) (2) (3). The registered person must ensure that the home has an effective staff team, with sufficient numbers and complimentary skills to support service users assessed needs.(Previous timescale of31/12/04 not met). The registered person must 30/09/05 ensure that there is further development of the homes quality assurance and monitoring system, and make it available to stakeholders and the Commission for Social Care Inspection. 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 YA15 YA28 Good Practice Recommendations The registered person should ensure that service users have access to a room in order to meet visitors. The registered person should after consultation with service users consider/design, suitable and safe access to all parts of the garden areas. I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 Page 20 Henderson and Harvard 3. YA24 The registered person should consider during the interim period, redecoration to areas in Harvard caused by wheelchair damage. Henderson and Harvard I56-I05 S17845 V221046 UI Henderson Harvard 210605 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Fairfax House Causton Road Colchester Essex C01 1RJ 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. 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