Inspection on 05/12/05 for Henderson and Harvard

This inspection was carried out on 5th December 2005.

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 5 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 21/06/05

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 CO5 0LJ Lead Inspector Andrea Carter Unannounced Inspection 05 December 2005 09:30 Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Henderson and Harvard Address Kelvedon Road Tiptree Colchester Essex CO5 0LJ 01621 819235 01621 819354 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) SCOPE Ms Sarah Lyndsey 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 DS0000017845.V268066.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability who may also have a physical disability (not to exceed 8 persons) One person, aged 65 years and over, who requires care by reason of a learning disability who may also have a physical disability, whose name was made known to the Commission in March 2003 21st June 2005 2. Date of last inspection 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 DS0000017845.V268066.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over a two week period, commencing with a site visit over one day which incorporated interviewing service users and discussion with the registered manager and staff members. The inspection included sampling documentary evidence in the form of individual service users care plans and the services policies and associated procedures. A full tour of the building and grounds was incorporated. A total of twelve standards were focused on with six meeting the appropriate standard and six having a minor shortfall. What the service does well: What has improved since the last inspection? The service has began the redecoration programme of Harvard, commencing with the main lounge area; the other areas will follow in due course. The appointment of new staff members and a new senior have increased the current team. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 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. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were looked at during this inspection. EVIDENCE: Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 9 Service users are supported to take risks as part of an independent lifestyle. EVIDENCE: The inspector interviewed one service user and it was evident the individual felt their needs were understood and met. There was clear verbal interaction around the preferences that were important to them and documentary evidence backed this up. There were risk assessments around the physical difficulties experienced daily and how to support the service user to overcome these and maintain a degree of independence. One individuals care plan was case tracked and included in depth information around all areas of daily living; to include moving & handling, communication, dietary needs and vulnerability issues. The evidence was comprehensive and was supported by risk assessments and associated management profiles. The service should ensure that there are clearly identified review dates and this implemented across the service. The infringement of rights should be updated to cross reference from the risk assessment and management plan. The home has a robust missing persons policy. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 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 the following standard(s): 15 16 and 17 Service users generally 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. EVIDENCE: Currently the service does not have the facilities to enable service users to meet within a private lounge area. Individuals have the privacy of their own room to meet with family and friends. The service is currently reviewing its establishment with a possible reduction in residents residing within the service. The vacant bedrooms would then be accessible to those individuals as lounge and meeting areas. Conversation with service users indicated that family relationships are readily supported by the service. Documentary evidence highlighted that this contact is the choice of the individual and their family and friends. This takes a variety of forms that include the telephone, the written letter cards and the recent Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 11 introduction of emails. Access to the home and visiting the family home is encouraged and supported. Service users spoken to outlined that there is a key worker system in operation. The individual is able to choose who supports them from the current team of staff. The daily routine of individuals is outlined clearly and freedom is evident with any restrictions being risk assessed. Support through access to the community and purchasing items of preference is evident, particularly with the Christmas season fast approaching. The service does not have provision for individuals to lock their own rooms with an override system. One service user interviewed stated they would like this facility with a personal key to be issued. Individuals met during the course of the inspection were relaxing in their rooms listening to music, on the computer or watching television. Service users meetings take place on a monthly basis. Included in this forum is the opportunity to discuss menu choices for the forthcoming week. Service users assist in the purchase of the weekly groceries at the local supermarket. Bread and milk is delivered daily to the unit. One of the service users types up the weekly menu sheets. Files sampled evidenced access to the community to participate in a variety of places for meals out. Those individuals that require feeding assistance are supported in choosing where and what they eat. The dietician supports individuals with dietary requirements and weights are monitored with regularity. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users receive personal support in the way they prefer and require. EVIDENCE: Service users interviewed outlined clearly that their preferences of waking and retiring are respected. The individual support received is documented clearly within the care plan. Supporting this information are risk assessments around moving and handling. Privacy and dignity is maintained at all times. Purchase of clothing is supported by the key worker system and observation of interaction between service users and staff, reflected the positive relationships that had developed. Individual choice of hair style and make up was a clear reflection of the people’s personality. Individual choice indicates the person to key work and support them in their daily lives. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Service users feel their views are listened to and acted on. EVIDENCE: Observation of the complaints procedure indicates that robust measures are in place within the service All service user are issued with leaflets outlining the complaints procedure and the appropriate individual or body they can contact to raise a complaint. Relatives and family of the service user receive information at the time of the annual review. Documentary evidence within the service complaints log was uptodate and timescales adhered to. The service should ensure that all documents are dated and signed and outcomes clearly written. Independent Advocacy services are accessed and used to facilitate the views of individual service users. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 28 and 30 Service users live in a homely, comfortable and safe environment. Shared spaces complement and generally supplement service users individual rooms. The home is clean and hygienic. EVIDENCE: The bungalow Harvard had commenced a process of colour choice. This enabled the service users to express their views and preferences for the various areas of the bungalow. Evidence of these choices was available within the home. The redecoration of the main lounge was commencing on the day of the inspection with the other areas to follow. The service currently employs a maintenance person for 35 hours per week covering two sites. Identification of specific works has been undertaken and is due to commence with a sloped area to the laundry room enabling access by individuals who are wheel chair users. Also refurbishment of the kitchen is planned and the guttering to the roof replaced. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 15 There was a recommendation from the previous inspection referring specifically to the garden area and the current difficulties around service users being unable to access all areas. To date no progress has been made in this area. Scope is reviewing all maintenance requirements of its premises; the proposal is for the patio to be refurbished with non slip tiles appropriate for the present service users group. The home presents as tidy, clean and hygienic. There is a sound infection control policy in place. The laundry facilities are a recent addition to the unit, built between the two original bungalows. The facilities are appropriate for their function containing one industrial washing machine with boil wash facilities and two industrial tumble dryers. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 35 and 39 An effective staff team generally supports Service Users. Service users individual and joint needs are met by appropriately trained staff. Service users are generally confident that their views underpin all self monitoring, review and development by the home. EVIDENCE: The service is currently running with three posts unfilled, two part time posts and one full time. The manger has undertaken a review of service users high and medium level care needs, in line with the residential forum guidance. The planned ratio of staff to service users is appropriate to those identified needs. The appointment of the vacant posts will complete the full staff team which currently are covered by agency staff and overtime from the current staff team. Three staff members files were reviewed. The newly appointed senior staff was undertaking the NVQ Assessors award and had a variety of courses completed relevant to the current role. On the day of the inspection training was being Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 17 provided to all staff from the unit and sister home in the area of Adult Protection. A staff member that had joined the service in September 2005 was underway with mandatory training and further courses planned. The induction was undertaken with the senior staff within the unit, but no documentary evidence was located on file. Good practice would be for the service to retain the induction information. A third staff member who commenced in 2004 had undertaken a specialist-training course in the area of external feeding pump training. The service is due to undertake BSL and makaton training. A staff profile sheet in relation to identification of training needs for individual staff was available in some staff files, but should be made consistent across the service. A development programme for the period 2005/2006 was available, but only identified mandatory training was listed. This should be expanded to include other specialist areas identified. Currently no staff has undertaken the LDAF induction training which is planned for Scope to provide as an in-house training resource. The development of quality assurance and monitoring system was a requirement from the previous inspection. The registered manager is awaiting information from the service manager in respect of the development and implementation of the system and no progress has as yet been made in this area. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards were looked at during this inspection. EVIDENCE: Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 19 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 x x x x Standard No 22 23 Score 2 x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x x x 2 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x 2 x 3 LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 2 16 3 17 Standard No 31 32 33 34 35 36 Score x x 3 x 2 x CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Henderson and Harvard Score 3 x x x Standard No 37 38 39 40 41 42 43 Score x x 2 x x x x DS0000017845.V268066.R01.S.doc Version 5.0 Page 20 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 YA9 Regulation 14(2)(a) Requirement Timescale for action 30/03/06 2 YA15 3 YA22 4 YA35 5 YA39 The registered person must ensure that the service users assessment of needs are kept under review. 23(2)(i) The registered person must ensure that service uses can meet visitors in private accommodation, which is separate from the service users own private rooms. 22(3) The registered person must ensure that all documentation appertaining to the complaints procedure is recorded in full. 18(1)(a) The registered person should ensure that newly appointed staff undertake the appropriate foundation and induction training. 24 The registered person must (10(ab)(2) ensure that there is further (3) development of the homes quality assurance and monitoring system and make it available to stakeholders and the Commission for Social Care Inspection.(This is carried over for the previous inspection with a timescale of 30/09/05). 30/10/06 30/03/06 30/04/06 30/03/06 Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 21 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 YA16 YA28 Good Practice Recommendations The registered person should ensure that service users have the opportunity to lock their own rooms and carry a key. The device fitted should have an override system. The registered person should after consultation with service users consider/design suitable and safe access to all parts of the garden areas. Henderson and Harvard DS0000017845.V268066.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 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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