Inspection on 30/01/07 for Hendon Road (3)

This inspection was carried out on 30th January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Hendon Road (3) 17/10/05

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 Andrew Windsor Unannounced Inspection 30th January 2007 10:00 Hendon Road (3) DS0000009641.V328812.R02.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 Hendon Road (3) DS0000009641.V328812.R02.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. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 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.V328812.R02.S.doc Version 5.2 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) 17th October 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 Pendle View. 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. Fees at Hendon Road vary from £345 to £375 per week. Information about the home is given to prospective service users on referral. Hendon Road (3) DS0000009641.V328812.R02.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 Hendon Road on 30 January 2007. The purpose of the inspection was to assess quality of life in the home, and check that the home meets legal requirements. The inspection comprised of looking around the home, and speaking to one service user and staff members. It also involved the examination of service users’ records and other documents. What the service does well: What has improved since the last inspection? What they could do better: Care plans at Hendon Road do not fully identify the needs of the service user, or adequately state how staff should meet these needs. Staff files do not contain the required pre-employment checks in all instances, so that service users are safeguarded. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 6 Quality Assurance systems at Hendon Road have not yet been developed. This means that avenues to improve the service are not being fully explored. 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. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1;2;5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Admission procedures meant that service users could be confident that their needs could be met. EVIDENCE: The inspector spoke to one service user, and examined his care file and other relevant documentation. Both service users currently supported have resided at Hendon Rd for some time. The home contained a detailed Statement of Purpose and Service User Guide, which had been recently reviewed. The service user spoken to stated that he had been involved in the admissions process, through the Mental Health Care Programme Approach. The file examined contained a written contract, that stated both the house rules and holiday options. This had been signed by the service user. This means that the service user was made aware of any restrictions placed upon them by living at Hendon Road. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6;7;9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users are encouraged to retain their independence, and make their own decisions through informed choices. Care plans examined did not fully identify service user needs and tell staff how to meet them. EVIDENCE: The inspector discussed care planning with one service user and the registered manager, and examined one care file. Hendon Road encourages service users to live independently, within a riskbased framework. The care plan examined contained a number of risk assessments, to ensure that the service user was safeguarded. The daily record of activity was completed to a high standard. A basic mental health care pathway was being provided, through documentation relating to the Care Programme Approach. Hendon Rd currently delivers its plan of care through a document entitled ‘Actions Set/Care Plan Reviews’. Unfortunately, this document did not fully Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 10 identify the needs of the service user, or adequately state how staff should meet these needs. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12;13;15;16;17 Quality in this outcome are is good. This judgement has been made using available evidence including a visit to this service. Independence and choice are encouraged, which enables service users to be part of the community. Contact with family members is encouraged. EVIDENCE: The inspector examined information relating to leisure activities for both service users, and discussed community participation with one service user and the registered manager. The service user spoken to stated that he prefers his own company, but staff members always encourage him to take part in activities outside the house. The service user always did his own shopping. He preferred to spend his leisure time listening to the radio, reading and doing crosswords. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 12 Documentation examined indicated that the other resident was more active in the local community. Activities included attending a local gardening group, walks, and trips to the local pub. Both residents took responsibility for their own meals, but were encouraged by staff to maintain a balanced diet. Hendon Road encourages contact with family and friends. One of the service users maintains regular contact with a close relative. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18;19;20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Health care needs are recorded, and addressed by accessing healthcare facilities in the community. Procedures for the administration of medication protect service users. EVIDENCE: The inspector spoke to one service user, and the registered manager. The care file of the service user was also examined. The service user spoken to stated that he had complete flexibility with his personal routines, and was able to get up, eat etc whenever he liked. The Care Programme Approach was used to monitor the long-term mental health of the service user. Records of contact with care professionals and the GP were being maintained. Service users are typically supported by the same staff member, to ensure consistency of care. Their healthcare needs are monitored by interacting with them on a day-by-day basis. Support is also available 24 hours a day, by contacting the core house (Pendle View). Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 14 None of the service users at Hendon Road were able to self-medicate. Documentation examined contained ‘Profiles for Prescribed Meds’, so that staff were aware of the purpose and side effects of medications used. A Medication Administration Record (MAR) chart was kept by staff for each service user, which also recorded when medication was brought into the home. Records of drugs disposed of were maintained at the core house. One of the service users chose to have his medication administered each day at the core house. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22;23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users were confident that their concerns would be listened to and acted upon. Service users were protected from abuse and harm. EVIDENCE: Hendon Rd had a policy on safeguarding adults, which had recently been reviewed. Similarly, staff members had received training in the safeguarding of adults. No safeguarding of adults issues have occurred since the last inspection. The complaints policy was a detailed document, which had also recently been reviewed. The service user spoken to was aware of the complaints procedure, and stated ‘If there’s anything wrong, I’ll soon moan about it. The staff would back me up on that’. No formal complaints have occurred at Hendon Road since the last inspection. The care plan examined contained a number of risk assessments, to ensure that the service user was safeguarded. The care plan also contained a document entitled ‘Fridge Contents Sheets’. This inventoried and recorded the disposal of food past its useable date, to ensure that residents were protected from food poisoning. Service users at Hendon Road are supported to manage their money. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 16 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;25;30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Hendon Road provides a homely and safe environment for service users. EVIDENCE: Hendon Road is a small semi-detached house, which is in keeping with the local community. The house was close to local transport, shops and other local amenities. Furnishings and fittings were comfortable and suitable for purpose. The home was found to be clean, tidy and free from offensive odour. Bedrooms were found to be safe, comfortable, and personalised. Bedrooms were lockable, and all service users had keys to both their rooms and the front door. Hendon Road does not have a Planned Maintenance Schedule. However, the registered provider does ensure that a representative of the organisation makes an unannounced visit to the home every month. Any issues with house are raised at this time. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 17 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;36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment procedures do not demonstrate that service users are safeguarded in all instances. Staff are receiving the training they need to do their jobs in a safe and competent manner. EVIDENCE: The service user spoken to indicated that staff tend to visit twice day, in order to ‘sit and chat, and make sure everything’s ok’. Assistance is also available from the core house at any time, by using the telephone. The inspector examined the files of two staff members. In one of the files examined, a Criminal Records Bureau Check had not been obtained prior to commencement of employment. This means that the service was unable to demonstrate that service users are safeguarded by its recruitment procedures. Of 6 staff members, 4 have completed a National Vocational Qualification (NVQ) at level 2 or above, which is 66 percent. Records indicate that staff are receiving on-going training. This means that staff members have received the training they need to be able to do their work in a safe and competent manner. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 18 Records examined at the time of inspection demonstrated that staff were being appropriately supervised, and receiving annual appraisals. This means that staff are being appropriately supported. Staff members have now being issued with a copy of the General Social Work Council’s code of conduct. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37;39;40;41;42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home benefits from an experienced and qualified registered manager. Procedures are in place to safeguard the health, safety and welfare of residents. The home should take steps to ensure that service users remain informed and consulted. EVIDENCE: The registered manager for Hendon Road has an NVQ4 in Care, and an RMA. She has been managing Hendon Road for the last 2 years. Policies and procedures at Hendon Road were up-to-date. Health and safety guidelines were available, which included the safe storage of hazardous materials. Records demonstrated that electrical and fire systems were tested and serviced at regular intervals. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 20 Quality assurance systems are Hendon Road would benefit from further development. At present, ongoing issues that require further attention are scheduled into a staff diary. Hendon Road did not contain any risk assessments for the environment. However, the care files of service users contained individual risk assessments for most issues. An annual satisfaction questionnaire has not been completed. This deficiency in measuring quality is denying service users the opportunity to have their say about how they see the service is operating. Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 21 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 3 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 2 3 3 3 X Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 22 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 YA6 Regulation Reg 14 Requirement The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. Timescale for action 30/04/07 3. YA39 Reg 24 Effective quality assurance and (1) (a) (b) quality monitoring systems, (2) (3) based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 30/04/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 23 Hendon Road (3) DS0000009641.V328812.R02.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Lancashire Area Office 2nd Floor, Unit 1, Tustin Court Port Way 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. 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