Inspection on 01/09/05 for Henley House

This inspection was carried out on 1st September 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 but made no statutory requirements on the home.

Other inspections for this house

Henley House 16/09/08

Henley House 03/10/07

Henley House 15/01/07

Henley House 23/02/06

Henley House 11/01/05

Henley House 11/08/04

Henley House 12/03/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Henley House 225 Whalley Road Accrington Lancashire BB5 5AD Lead Inspector Lynn Mitton Unannounced 01 September 2005 10:00 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 Older People. 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. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Henley House Address 225 Whalley Road Accrington Lancashire BB5 5AD 01254 235386 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) Wellfield & Henley House Ltd Ms Susan Margraret Brady Care Home Only Personal Care (PC) 23 Category(ies) of Old age, not falling within any other category registration, with number (OP) 23 of places Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The service shall at all times, employ a suitably qualified manager who is registered with the CSCI. Date of last inspection 11 January 2005 Brief Description of the Service: Henley House is registered with the Commission for Social Care Inspection to provide accommodation and personal care to 23 older people. The property is Victorian and set in well-maintained gardens. The home is located on the main Whalley Road and is close to local shops, this road is also situated on a main bus route that offers transportation to all towns in the Hyndburn area. Accommodation is provided in 23 single rooms, 18 of which have en-suite facilities. There were two lounge areas and a dining area. Smoking is permitted in a specially designated area. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and lasted approximately 6 hours. There were 21 residents accommodated at this time. A tour of the communal areas of the home took place. Over the course of the inspection three of the staff on duty, approximately 12 residents plus the registered person the registered manager and deputy manager were spoken to, and interaction between the residents and staff members were observed. Throughout the report there are various references to the “case tracking” process, this is a method whereby the inspector focuses on a small representative group of service users. Records pertaining to these people were inspected. Policies and practices were also read. Three visitors to the home on the day of the inspection had completed the Commission’s satisfaction survey. These indicated that overall they were satisfied with the level of service received at Henley House. What the service does well: Residents were fully assessed before they were admitted to the home. Written information was in place for each resident regarding their care and health needs and how they were to be met. This information was up to date. Regular activities ensured that residents were stimulated and had opportunities to try new things. Many of the care staff team had considerable experience in caring for older people, and were well established at Henley House, ensuring continuity for residents. Residents spoken to valued the care they received at Henley House. There were written procedures for protecting residents in place, and staff were aware of the procedures to follow. The general décor of the home provided warm comfortable and clean surroundings that were suitable for their purpose. Residents had appreciated the garden and seating area during the summer months. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 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. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3 & 6 The written information provided in the statement of purpose and service user guide provided a clear picture of the homes facilities and services, enabling prospective residents to decide if the home was right for them. The admission procedure for new residents ensured that information about their care needs was obtained before they arrived. This enabled staff to have a clear understanding of what care interventions were needed. EVIDENCE: The statement of purpose and service user guide now contained all the information needed for a prospective resident to understand how the home was run and what facilities were offered. Assessments to determine the care needed were completed prior to new residents being admitted. The inspector saw two of these, which were completed appropriately. Letters should be sent to residents advising them that Henley House was able to meet their needs. Intermediate Care is not offered at Henley House. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7 & 8 Care plans contained sufficient detail to ensure that care and health needs were identified and care interventions documented. EVIDENCE: The inspector looked at two residents care plans. On them was information identifying the resident’s care and health needs, and how these were to be met by the care staff team. There was evidence that both care plans had been reviewed within the past week. There were also records of residents health needs being met (including records of weight). Each resident was registered with a doctor from the local practice. One resident told the inspector, “I’m very happy here”. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 10 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12 & 14 A regular programme of activities ensured that residents had opportunities for their enjoyment, mental and physical stimulation. EVIDENCE: The inspector noted that a number of residents were involved in their own hobbies for example, two residents were knitting, and another two were colouring in a sketchbook. It was noted that a trip to Blackpool was planned for October, and some residents were already looking forward to this trip. Concerts were organised in the home approximately every month. One resident said “we have entertainers here every now and again”, another said, “we can sit out in the garden on nice days”, and another “sometimes we play Bingo – I’d like to play more often”, another told the inspector, I would like to play whist” Religious representatives attended Henley House and the residents spoken to derived considerable comfort from this. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 11 The inspector noted that residents were treated with dignity and respect by care staff, and staff spoken to could give examples of how they made sure that resident’s privacy was ensured. Information regarding the advocacy service, for any residents without a next of kin was now included in the homes documentation and was also available on notice board. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 Staff spoken to knew how to protect the residents in their care. The written procedures for responding to an allegation of abuse were in place, and staff were aware of the procedures to follow. EVIDENCE: Two care staff spoken to by the inspector could define the different types of abuse. They knew what to do, if they had any concerns about residents wellbeing, and had an awareness of the whistle blowing policy. The inspector advised those staff that they could come to the Commission at any time if they had concerns. Documentation was in place for protecting residents from abuse of any kind. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 13 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 26 The layout and décor of the home was suitable for the residents accommodated and provided comfortable surroundings. The home was clean, tidy, warm and mostly free from offensive odours. EVIDENCE: One resident said, “I have a lovely room and I’m quite content”. On the day of the inspection, the home was found to be clean, tidy, warm and odour free. The garden to the front and rear of the home was well tended, and residents advised the inspector that they had enjoyed sitting out on sunny days. The home appeared well maintained. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 14 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 28, 30 The residents and visitors spoken to highly valued the care they received at Henley House. Training was being undertaken to ensure that care staff had the skills to care for the residents. Procedures for recruitment of staff and checks to safeguard residents must be in place. EVIDENCE: One visitor’s questionnaire commented that they felt the home was short staffed at times. The home was fully staffed at the time of the inspection. 4 staff had achieved NVQ level 3 qualification and one had obtained NVQ 2. The inspector was advised that 4 care staff were due to begin NVQ 2 training in September 2005. The inspector observed residents being supported by competent staff. Two staff recruitment files were case tracked and both were found to have minor shortfalls of that required by the Commission. These were discussed with the registered manager. The registered manager advised the inspector that the in house induction and foundation training met TOPSS specification. This ensures that at the beginning of their employment, care staff have had the training needed to ensure that they can competently fulfil their role. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 15 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 36 & 38 The attitude of the staff and management was to run the home around the needs and choices of the residents. EVIDENCE: The registered manager was undertaking the NVQ 4 qualification in care and management and the registered managers award. It was anticipated this would be completed by January 2006. The deputy manager was also undertaking this qualification. Staff advised the inspector that discussions took place on a daily basis regarding the residents changing needs and ongoing issues within Henley House. The minutes of staff meetings were seen and so far, three had been held in 2005. Issues discussed were pertinent to the health & welfare of the residents and staff team. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 16 Accident records were seen and the inspector advised that all elements of the record must be completed, including the dates and if whether there were any apparent injuries. The homes quality monitoring format had been implemented and a resident survey had been completed in January 2005 the results of which had been published. The inspector was advised that a further survey was due to be conducted in the near future. The inspector advised that the survey form be dated. Whilst case tracking, it was noted that risk assessments had been completed in order to establish and ensure residents continued safety; however the inspector advised that an assessment form should be completed for each risk. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 2 x x x HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 x 10 x 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 x 14 3 15 x COMPLAINTS AND PROTECTION x x x x x x x 3 STAFFING Standard No Score 27 x 28 2 29 x 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 2 x 3 x x 2 x 2 Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 18 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 OP3 Regulation 14(1d) Requirement The registered person shall confirm in writing that the home is able to meet the residents needs. The registered person is required to ensure that at all times suitable qualified staff are working at the care home, and that they receive training appropriate to the work they are to perform. The registered person must ensure that risk assessements are completed for each identified risk. Timescale for action 28th October 2005 31st December 2005 2. OP30 OP28 18 (1) (a) & (c) Schedule 2&4 3. OP38 13 30th December 2005 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 OP31 OP36 Good Practice Recommendations The registered manager should obtain the NVQ 4 in care and management qualification (or equivalent) by 2005 Care staff should receive formal supervision at least 6 times a year. Henley House F57 F07 S9436 Henley House V233248 160805 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, Clayton-Le-Moors Accrington Lancashire. 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. 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