Inspection on 23/02/06 for Henley House

This inspection was carried out on 23rd February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report 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 01/09/05

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 Mrs Lynn Mitton Unannounced Inspection 23rd February 2006 10:00 X10015.doc Version 1.40 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 Henley House DS0000009436.V281523.R01.S.doc Version 5.1 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 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 DS0000009436.V281523.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Henley House Address 225 Whalley Road Accrington Lancashire BB5 5AD 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) 01254 232763 01254 237022 Wellfield & Henley House Ltd Ms Susan Margaret Brady Care Home 23 Category(ies) of Old age, not falling within any other category registration, with number (23) of places Henley House DS0000009436.V281523.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The service shall, at all times employ a suitably qualified manager who is registered with the Commission for Social Care Inspection. 1st September 2005 Date of last inspection 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 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 DS0000009436.V281523.R01.S.doc Version 5.1 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 22 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. What the service does well: One resident said; “The care staff are very helpful and patient”. One resident told the inspector “Its great living here – like home from home”. From observations and examining care plans, the inspector felt that staff knew resident’s needs and how they were to be met very well. Practices for managing and administering medication were generally in good order. Personal support was offered in accordance with resident’s wishes, and in a way that promoted privacy dignity and independence. Visitors were made welcome at Henley House, and could visit at any reasonable time. Mealtimes were a social occasion and the food served was varied and enjoyed by the residents. There was a clear complaints procedure and staff spoken to had a good understanding of what to do if a complaint was made. The layout and décor of the home was suitable for the residents accommodated and provided comfortable surroundings. The home was clean, tidy, warm and free from offensive odours. Henley House DS0000009436.V281523.R01.S.doc Version 5.1 Page 6 Staff numbers were sufficient to meet the needs of the residents. The care staff team were experienced in meeting the resident’s needs. Staff training was ongoing which would ensure that the care staff team were able to competently care for the residents. Procedures for recruitment of staff and checks to safeguard residents were in place. The attitude of the staff and management is to run the home around the needs and choices of the residents. 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 DS0000009436.V281523.R01.S.doc Version 5.1 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 Outcomes Statutory Requirements Identified During the Inspection Henley House DS0000009436.V281523.R01.S.doc Version 5.1 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 the following standard(s): OP3 & OP6 The admission procedure for new service users ensured that all information about their care needs was obtained before they arrived for a stay. This enabled staff to have a clear understanding of what they needed to do for them. EVIDENCE: Any new resident wishing to stay at Henley House would have an assessment completed prior to their admission. Two residents were case tracked and both had an assessment document in place. Intermediate care is not offered at this home. Henley House DS0000009436.V281523.R01.S.doc Version 5.1 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 the following standard(s): OP9 & OP10 From observations and examining care plans, the inspector felt that staff knew resident’s needs and how they were to be met very well. Practices for managing and administering medication were generally in good order. Personal support was offered in accordance with resident’s wishes, and in a way that promoted privacy dignity and independence. EVIDENCE: 2 care plan were case tracked; on them was information identifying resident’s care and health needs and how they were to be met by care staff. The contents of the daily records were discussed with the registered manager. The inspector examined the homes medication system. A monitored dosage system was in place. Consent of administration of medication forms were seen. The medication administration record sheets were seen and in order. The registered person and inspector discussed double signatures for any hand written entries on the sheets. Oxygen storage notices were put in place. Regular temperature checks of the medication storage fridge were made. The registered manager and inspector discussed dating any liquid medication (for Henley House DS0000009436.V281523.R01.S.doc Version 5.1 Page 10 example eye drops) bottles with a limited shelf life, of the date they were opened. Stock piling of drugs was also discussed. The administration of medication for senior staff was ongoing at the time of the inspection. Residents spoken to told the inspector that they were spoken to and treat with dignity and respect and gave examples of this. The inspector observed very positive, caring and respectful interaction between residents and care staff. Henley House DS0000009436.V281523.R01.S.doc Version 5.1 Page 11 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 the following standard(s): OP13 & OP15 Visitors were made welcome at Henley House, and could visit at any reasonable time. Mealtimes were a social occasion and the food served was varied and enjoyed by the residents. EVIDENCE: A number of visitors were seen coming to the home. One visitor told the inspector “I have no complaints, I am always looked after and made very welcome whenever I come”. The inspector ate lunch with some of the residents on the day of the inspection. Complimentary comments were made by a number of residents about the quality and quantity of food served. One resident said; “we get very good food” another said; “there’s lots of variety”. A record of meals served was made. The inspector advised that any variations made to the main menu (for example, diabetic diet) should also be recorded. The day’s menu was recorded in the dining area so that residents knew what food was due to be served. The inspector and registered manager discussed the practice of care staff supporting residents whilst eating their lunch. Henley House DS0000009436.V281523.R01.S.doc Version 5.1 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 the following standard(s): OP16 There was a clear complaints procedure and staff spoken to had a good understanding of what to do if a complaint was made. EVIDENCE: There was a clear complaints procedure in place. This was given to new residents when they were admitted to the home. A copy was also kept in the information pack kept in the reception area of the home. Two care staff spoken to by the inspector had an understanding of the complaints procedure, ensuring that any complaints would be dealt with appropriately. The Commission had received no formal complaints. Henley House DS0000009436.V281523.R01.S.doc Version 5.1 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 the following standard(s): OP19 The layout and décor of the home was suitable for the residents accommodated and provided comfortable surroundings. The home was clean, tidy, warm and free from offensive odours. EVIDENCE: On the day of the inspection, the communal areas of home were found to be clean, tidy, warm and odour free. The home appeared well maintained. The inspector was advised that at the time of the inspection there was a 16 hour domestic vacancy. Since the previous inspection the outside of the home had been repainted and one bedroom had also been redecorated. Henley House DS0000009436.V281523.R01.S.doc Version 5.1 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 consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP27, OP28 OP29 & OP30 Staff numbers were sufficient to meet the needs of the residents. The care staff team were experienced in meeting the resident’s needs. Staff training was ongoing which would ensure that the care staff team were able to competently care for the residents. Procedures for recruitment of staff and checks to safeguard residents were in place. POVA 1st checks must be completed for all new staff in future. EVIDENCE: The staffing rota was examined and it demonstrated that there were 3 care staff on duty between 8am and 10pm. During the night there were 2 wake and watch staff on duty. An on call senior staff member was always available. The inspector observed residents being supported by competent and caring staff. 5 out of the 18 care staff team had completed their NVQ level 2 or NVQ level 3 training. A further 10 care staff were undertaking NVQ 2 training. Other recent staff training included emergency 1st Aid, Dementia and Administration of Medication. Other staff training discussed included food hygiene and moving and handling. The inspector advised all new staff must receive induction training to TOPSS specification within 6 weeks of appointment to the post. Henley House DS0000009436.V281523.R01.S.doc Version 5.1 Page 15 One new care staff’s personnel file was case tracked and this was found to have the information required to evidence that staff were employed in accordance with the Care Home Regulations. The inspector advised the registered manager and registered person of the POVA 1st check that must be done in all cases prior to staff starting work at Henley House. Staff meetings were being held the last one being in December 2005 and the next on planned for March 1st. Henley House DS0000009436.V281523.R01.S.doc Version 5.1 Page 16 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 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): OP31, OP35, OP36 & OP38 The attitude of the staff and management is to run the home around the needs and choices of the residents. Risk assessments must be completed to enable residents to take responsible risks. EVIDENCE: The registered manager advised that she had now completed her NVQ 4 in care qualification, and also the registered manager’s award, which had been submitted and was awaiting verification. The deputy manager had also completed her NVQ 4 training. The registered person visits the home most days. The inspector was advised that all residents’ finances were dealt with by the residents themselves, their next of kin power of attorney or families. Henley House DS0000009436.V281523.R01.S.doc Version 5.1 Page 17 The inspector was advised that 1:1 supervisions were being undertaken more frequently. The staff member case tracked had been in post for just under one month. The inspector advised that good practice would be for newly appointed staff to have monthly 1:1’s as part of their trial period. The inspector noted that on the care plan’s case tracked a Waterlow risk assessment had been completed for both residents. An additional risk assessment completed for one resident had not been completed or signed. Henley House DS0000009436.V281523.R01.S.doc Version 5.1 Page 18 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 Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 X 13 3 14 X 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X X X 3 3 X 2 Henley House DS0000009436.V281523.R01.S.doc Version 5.1 Page 19 Are there any outstanding requirements from the last inspection? Yes 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 OP28 Regulation 18 (1a&c) Requirement Timescale for action 01/07/06 2. OP30 3. OP38 The registered person must ensure that a minimum of 50 of care staff have achieved the NVQ 2 in Care award. 18 (1a) The registered person is required (c)Sch 2 & to ensure that at all times 4 suitable qualified staff are working at the care home, and that they receive training appropriate to the work they are to perform. 13 The registered person must ensure that risk assessments are completed for each identified risk. 01/07/06 01/07/06 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. Refer to Standard OP15 Good Practice Recommendations A copy of the menu’s should be available at the home. Any variations made to the main menu (for example, diabetic diet) should be recorded Henley House DS0000009436.V281523.R01.S.doc Version 5.1 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 Henley House DS0000009436.V281523.R01.S.doc Version 5.1 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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