Inspection on 17/10/05 for Hendon Road (3)

This inspection was carried out on 17th October 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hendon Road (3) 30/01/07

Hendon Road (3) 18/07/05

Hendon Road (3) 18/11/04

Hendon Road (3) 16/04/03

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

CARE HOME ADULTS 18-65 Hendon Road (3) 3 Hendon Road Nelson Lancashire BB9 9JL Lead Inspector Mrs Keren Nicholls Unannounced Inspection 17th October 2005 12:15 Hendon Road (3) DS0000009641.V259770.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 Hendon Road (3) DS0000009641.V259770.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. Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Hendon Road (3) Address 3 Hendon Road Nelson Lancashire BB9 9JL 01282 690703 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) Pendle Residential Care Limited Mrs Ann Suleman Care Home 2 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (2) of places Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The service may accommodate up to a maximum of 2 service users in the category mental disorder, excluding learning disability or dementia (MD) 18th July 2005 Date of last inspection Brief Description of the Service: 3, Hendon Road (accommodating 2 younger adults) is part of Pendle Residential Care Ltd. (Dispersed Homes Scheme) in Nelson. This is a semiindependent living scheme for younger adults who have mental health problems. This dispersed house has staff support according to the assessed need of the residents. A designated house keyworker visits at least once a day and care support is available in the evening and at week-end as needed. Senior staff are on call at night and 24 hour emergency support is provided by the core house at Pendleview. Further support is provided by visits from the registered manager and provider. Hendon Road is a small semi-detached house, located in a quiet residential area, near to local shops. Nelson town centre shops and other amenities are a short distance away. The house has on-street parking and pleasant gardens to the front and back. Transport in staff cars is provided for service users. There are two single bedrooms and a house bathroom (shower and WC) on the first floor, and kitchen, dining/lounge and living room on the ground floor. Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second unannounced inspection to be carried out to Hendon Road during the inspection year from April 2005 to April 2006. The visit took place between 12:15 and 3:30pm (3.15 hours) and included discussion with the house keyworker and registered manager at the ‘core’ house, Pendleview. The inspector spoke to the person resident at Hendon Road, looked round the house and gardens and examined written information, including records. What the service does well: What has improved since the last inspection? What they could do better: To make sure that everyone knows what to do, the policies and procedures should be available at the home for staff and residents to read. The manager should check that the policies and procedures regarding safe storage and disposal of medicines are followed. The old registration certificates should be returned to the Commission. In order to protect residents’ rights and make the responsibilities of both parties clear, the manager should agree with residents a costed contract that includes agreements regarding paying for annual holidays (or equivalent). Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 6 The manager should continue to respect the suggestions and opinions of residents, by adding comments sections to the annual ‘customer’ satisfaction survey and ensuring this can be completed anonymously. Staff should have a copy of the General Social Care Council’s codes of conduct for social care workers, to help them to act in residents’ best interests. To protect the dignity of residents the staff should help with periodic ‘spring cleaning’ and the front bedroom carpet should be shampooed. 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. Hendon Road (3) DS0000009641.V259770.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 Hendon Road (3) DS0000009641.V259770.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): 2 and 5 Residents had been consulted about their needs and wishes prior to admission. Trained people had assessed these needs, to ensure that they could be met by the home. In order to protect both parties’ rights and responsibilities, the home needs to ensure that individual contracts are reviewed with residents. EVIDENCE: Residents had been involved in assessments and in choosing to live at Hendon Road through mental health Care Programme Approach (CPA) arrangements. Needs had been properly and fully assessed by trained persons under CPA and copies of assessments were kept in personal files. A contract had been agreed with the resident, but the manager should ensure that this is reviewed to include; • changes in terms and conditions of occupancy, • room to be occupied, • personal support needs, • any “rules”, • the fees charged, • what the fees cover (including a weeks holiday or equivalent – see also Standard 14.4), • the rights and responsibilities of both parties (including insurances) and • a summary of the resident’s care plan. Hendon Road (3) DS0000009641.V259770.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): 7, 8 and 9 There were satisfactory arrangements to ensure that residents were properly consulted about their care. Staff respected the resident’s rights to make independent decisions, within a risk-assessment framework. EVIDENCE: The resident said that he made his own decisions and choices about how to run his home and occupy his time. He thought that staff listened to his views and opinions. He said he was able to have what he needed and influence decisions about the home and staff gave him the support he needed to be independent. The resident was very aware of the risks involved in living independently and described how he took appropriate action to minimise risks. The house keyworker had documented risk assessments and discussed responsible risk taking with the resident. Hendon Road (3) DS0000009641.V259770.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): 11, 13, 14, 16 and 17 The staff enabled the resident to participate in appropriate leisure and social activities. Staff respected rights and helped the resident with personal development and retaining community links. Healthy eating was promoted. EVIDENCE: The resident said was enjoying having sole responsibility for his house. Although he knew he would be sharing when a new resident was admitted, he liked living alone. The resident said he liked to go for a walk and to the shops for food and his newspaper every day. Indoors he enjoyed reading, videos, the TV and radio. He said he was very satisfied with his life at present and with the support he had from the staff. He said he had a good diet, with fresh food. The house keyworker explained that she was supporting the resident with healthy eating. This person did not wish to go away on holiday and did not enjoy day trips. It has been recommended therefore that the manager should ensure an equivalent to a weeks holiday is agreed in this person’s contract (see also Standard 5). Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 11 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, 19 and 20 Personal support was provided in a flexible and individual manner, which respected residents’ dignity and independence. Keyworker staff supported the resident in managing healthcare needs. Staff had not followed procedure for disposing of some medication. EVIDENCE: The resident explained that he made his own choices about personal routines. He said he was very happy with the help and support he had from his care workers, who respected his needs and wishes and privacy. He was confident about assessing his own healthcare, but valued the support of the keyworker, who helped to make appointments and ensured regular screening checks were undertaken and recorded. There were good policies and procedures and systems in place for safe storage and administration of medicines and staff had been appropriately trained. However, medicine for one resident who had left the home was stored in an unlocked cupboard in the dining room. This was discussed with the house keyworker who made arrangements for removal. The manager must ensure that in future policies for disposal of medicines are followed. Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 12 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): 23 Procedures were in place to respond quickly and effectively to suspicion or evidence of abuse. Residents and staff had a good understanding of the procedures. EVIDENCE: The home had a good recruitment process, which helped to ensure that staff were suitable to work with vulnerable adults. Protection procedures had been amended, so they followed ‘No Secrets in Lancashire’ guidance. Staff had received training in protecting residents from and responding to allegations of abuse. One care worker described how she had gained a deeper understanding of protection issues by following the procedure in respect of receiving gifts. The resident said he felt safe and supported and had no concerns regarding protection issues. Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 13 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, 25, 26, 27 and 30 The home was non-institutional and had a satisfactory standard of décor and cleanliness. There were no obvious hazards to safety and the building and outside paved areas were maintained in good order, providing a safe, comfortable and ‘homely’ environment, which was appropriate for the current resident. EVIDENCE: Hendon Road provided spacious communal accommodation for two residents. The house is near to local transport, shops and other amenities and is in keeping with other houses in the locality. There was information about room sizes in the Scheme’s statement of purpose and Service User’s Guide. The premises were inspected with the permission of the resident. The house had sufficient and suitable light, heat and ventilation. The furniture, fittings and decoration were comfortable and of suitable quality. The resident was doing a very good job of keeping the house clean, but needs staff help to ‘deep clean’ the house (including shower room and bedrooms) every few months. The front bedroom carpet should be thoroughly cleaned/shampooed. The registered provider carried out maintenance, renewal and refurbishment requirements and safety checks in a timely fashion. Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 14 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): 31 and 34 Properly ‘vetted’, trained and well-motivated care workers provided flexible and individual support to meet residents’ needs. Staff had a good self awareness of their capabilities and understood their own and others roles and responsibilities. EVIDENCE: A good recruitment process ensured that staff were properly vetted and suitable to work with vulnerable adults. Residents were involved in staff selection. Care workers had clearly defined job descriptions. The house keyworker had recently been promoted to deputy manager and a new job description was being agreed. A care worker explained how her induction training had included understanding the home’s aims and objectives and this was confirmed through supervision with the manager. The staff had good self-awareness of their limitations and when to ask for professional advice. NVQ and in-house training had promoted staffs’ reflective practice. The resident said that he liked all the staff. He thought they knew and understood him and met his needs very well. A care worker spoken with did not have knowledge of or a copy of the General Social Care Council’s codes of conduct for social care workers (31.5). To promote the best interests of residents, the manager should ensure that every member of staff has a copy of and complies with the codes in their work. Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 15 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): 39, 40 and 43 Systems that encouraged and enabled residents to express their views and opinions were in place. Sound and comprehensive policies and procedures underpinned care and health and safety practices, ensuring that risks to service users were minimised. EVIDENCE: The home’s quality assurance system included: • • • • • • • An annual service user satisfaction questionnaire. Individual discussion with residents to gain their views and opinions. Staff having sufficient time to spend with residents getting to know them well and to meet their needs. Regular management meetings to discuss progress and planning. Regular staff meetings to encourage staff suggestions. Encouraging feedback from other stakeholders (family, mental health professionals etc.) on how well the home is achieving its aims. Ensuring residents had access to CSCI inspection reports and encouraging residents to speak to the inspector. DS0000009641.V259770.R01.S.doc Version 5.0 Page 16 Hendon Road (3) • • • Progressing requirements and recommendations from inspection reports. Regularly reviewing policies and procedures. Using the Investors in People quality assurance system award as the basis for training and development of all staff involved in the care and support of residents at Hendon Road. The resident said that staff listened to his views and acted upon his ideas and suggestions. He thought the staff were friendly and approachable and said he could always contact the manager by telephone if he wanted to. The registered provider visited regularly and the resident said he was very good about responding to his requests. One resident at the core house suggested that residents should be included in staff appraisals. It was also suggested that the annual satisfaction questionnaires should include comments sections and should have the option to be anonymous. Comments forms should be available for residents to complete at any time if they wish. The manager had completed a review of policies and procedures and staff were in the process of reading the amended ones. The resident said there was a set at the home, although he could not find them at the time of inspection. However, he did have copies of those that affected him most (such as the fire procedure and health and safety risk assessments). Insurances were current and the registered provider had submitted an up to date business and financial plan for the Scheme. This included plans for maintaining and upgrading the property and staffing training plans and budgets. Lines of accountability were clear and the resident had access to all layers of management. Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 17 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 2 Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 2 3 X X 2 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 2 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score 2 X X 3 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Hendon Road (3) Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score X X 2 3 X X 3 DS0000009641.V259770.R01.S.doc Version 5.0 Page 18 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA20 Regulation 13(2) Requirement The manager must ensure that the medication procedures regarding safe storage and disposal are followed. Medicine for one person who had left the home must be disposed of correctly. Timescale for action 18/10/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 Refer to Standard YA5 YA14 Good Practice Recommendations The registered manager should review and agree a written and costed contract/statement of terms and conditions of residence with residents (5.1) This recommendation carried forward from the last inspection: The manager should agree holiday options (as part of the basic contract price) with the residents (14.4) The front bedroom carpet should be thoroughly cleaned (26.2(vi)) Although residents were keeping the home ‘surface’ clean, it is recommended that staff help the residents with a thorough ‘deep spring clean’ every few months (30.1) DS0000009641.V259770.R01.S.doc Version 5.0 Page 19 3 4 YA26 YA30 Hendon Road (3) 5 YA31 6 YA39 The manager should ensure that every staff member has a copy of, is familiar with and complies with the General Social Care Council’s codes of conduct for social care workers (31.5) The annual satisfaction questionnaires should include comments sections and should have the option to be anonymous (39.6). The suggestion that residents should be included in staff appraisals and that comments forms should be available for completion at any time should be considered. Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington BB5 5JB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Hendon Road (3) DS0000009641.V259770.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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