Inspection on 28/02/06 for Henry Street Residential Home

This inspection was carried out on 28th February 2006.

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 no outstanding requirements from the previous inspection report, but made 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Henry Street Residential Home 27/11/08

Henry Street Residential Home 06/12/07

Henry Street Residential Home 28/06/07

Henry Street Residential Home 06/06/06

Henry Street Residential Home 15/12/04

Henry Street Residential Home 05/07/04

Similar services:

Coopers Mill Ltd

Bramley Avenue (73)

Paradise Lodge

Grangewood

Upaya Ananda

Newton Court (1-2)

Kings Lane (32)

Pemdale

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

CARE HOME ADULTS 18-65 Henry Street Residential Home 21 Henry Street Debenham Stowmarket Suffolk IP14 6RH Lead Inspector Tina Burns Unannounced Inspection 28th February 2006 10:45 Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 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 Henry Street Residential Home DS0000024412.V285390.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 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. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Henry Street Residential Home Address 21 Henry Street Debenham Stowmarket Suffolk IP14 6RH 01728 861122 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) H4037@mencap.org.uk Royal Mencap Society Mr Richard Baker Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2004 Brief Description of the Service: Henry Street was first registered as a care home for four people with learning disabilities in 1989. It is a purpose-built bungalow situated in a residential housing area on the outskirts of Debenham, Mid Suffolk. The home is managed and staffed by Mencap but the property itself is owned and maintained by Sanctuary Housing. The building is spacious and simple in design and layout. It incorporates lounge and dining facilities in addition to single bedroom accommodation. All areas of the home are wheelchair accessible. The home also has the advantage of a spacious secure garden and small sensory room. The home has easy access to local shops and amenities including a leisure centre, post office, pubs, café and public transport. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place on a weekday between the hours of 10.45am and 6.15pm. The process included a tour of the building, observations of staff and service user interaction, and the examination of a number of documents including residents care plans, medication records, the staff rota and a number of policies and procedures. Throughout the day the inspector met all of the residents, all of whom had high level and specialist communication needs, and spoke with four members of staff on duty at the time of the inspection. The manager, Mr Richard Baker, was not on duty himself but did join the inspector for a short while at the end of the day, as did the area manager, Mr Bill Cook. What the service does well: What has improved since the last inspection? What they could do better: The home needs to ensure that care plans/residents profiles and risk assessments are regularly reviewed and updated as appropriate. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 6 The home also needs to ensure that all staff undertake adult protection training and policies and procedures in place for residents finances are reviewed and updated appropriately. The home should also consider having a safe installed for holding resident’s cash. The Behaviour Management plan in place for one resident should be signed and agreed by professionals and representatives in addition to the homes manager. Policies and procedures need to be easily accessible, current and upto-date and the home needs to ensure that records are secure and held in accordance with the Data Protection Act 1998. Finally the home needs to ensure that staff adhere to food hygiene guidelines and fire extinguishers are appropriately ‘fitted’ and serviced on an annual basis. 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. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 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 Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 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 & 5. Residents can expect the home to undertake a comprehensive assessment of need. Furthermore, they can expect to have appropriate ‘agreements’ in place in relation to their tenancy’s and support. EVIDENCE: At the time of the inspection there were no new residents, all four residents were long-term, established residents that had lived at the home for some years. However, the records examined of one resident included an assessment of need that had been completed by the residents ‘key worker’ within the past 7 months. The assessment covered a wide range of physical, social and emotional needs and was detailed and informative. The records held also included copies of assessments undertaken by local authority care managers. The resident’s records seen also included copies of their tenancy/supported housing agreement. The agreement was ‘user friendly’ and had been produced using pictures and symbols with the needs of the residents in mind. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 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): 6, 7 & 9. Residents can expect to have detailed care plans and risk assessments in place but they cannot be certain that they will be regularly reviewed to reflect their changing needs. EVIDENCE: The care plan of one resident was examined. It was comprehensive and reflected the needs identified in the resident’s assessments. Further records also included a resident’s profile that provided a summary of the resident’s background, skills, likes, dislikes and personal goals. Risk assessments were also in place so that the resident could participate safely in activities within the home and community. However, there was no evidence that the home had reviewed the resident’s profile or risk assessments since 2004. Records seen, observations made and staff spoken with indicated that resident’s are supported appropriately so that they can make decisions about their lives. Staff had training in and were committed to working within a ‘Person Centred’ approach and had a good understanding of residents needs, likes and dislikes. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 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, 14, 15, 16 & 17. Residents can expect to have opportunities for personal development and be encouraged to participate in appropriate social and leisure facilities. Furthermore, residents can expect to be fully involved in the planning and preparation of their meals. EVIDENCE: Records seen, staff spoken with and observations made indicated that residents are encouraged to develop and maintain independent life skills. The resident’s records that were examined included comprehensive information about the individual’s skills/abilities and the level of support required in a wide range of areas. They also evidenced that the home supports residents to engage in appropriate leisure activities including annual holidays. On the day of inspection staff were observed supporting residents with general household routines and in the preparation of breakfast and lunch. Staff on duty confirmed that the home does not employ a cook and residents are encouraged to participate in planning menus, shopping for food and the preparation of meals. Staff spoken with were confident that they knew residents likes and dislikes and these were incorporated into the menu. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 11 Records seen and staff spoken with also confirmed that residents are supported to maintain contact with their families and friends, either by providing support for residents to visit them or welcoming friends and families into the home. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 & 21. The home has appropriate arrangements in place for ensuring that residents physical and emotional health needs are met. Furthermore, residents are protected by the homes procedures for dealing with medicines. EVIDENCE: The residents care plan seen identified health care needs and included formats for monitoring health and weight and records of medical visits such as GP’s, community nurses and outpatients appointments. Medication records were examined and seen to be accurate and complete with all entries signed and dated appropriately. Records included the individual’s photograph and medication profile. Medication was appropriately stored in a locked cabinet in the office. Staff training was provided by ‘Boots Chemist’. The resident’s records examined included the arrangements to be followed in the event of the resident’s death, signed by the resident’s representative, and demonstrating that the home had appropriately consulted the resident’s relatives. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23. Residents cannot be assured that they are entirely safeguarded from abuse or harm. EVIDENCE: The home had a ‘complaints log’ in place. There had been no complaints recorded since the previous inspection. Two staff spoken with said that they had not undertaken Protection of Vulnerable Adult training and were not familiar with the local authority guidelines on adult protection. However, on the day of inspection a matter of concern was reported to the area manager who responded appropriately by following inter agency guidelines and disciplinary procedures. The last inspection found that Criminal Record Bureau checks were in place for care staff but not in place for the domestic staff however, on this occasion the domestic had a satisfactory enhanced disclosure form in place dated November 2005. Discussion with the manager at the end of the day centred on the ‘challenging’ behaviour of one resident. The manager explained that a multi disciplinary meeting had taken place (minutes were not available) and the vulnerability of other residents was being assessed. Furthermore, interim measures had been put in place to protect the other residents including a ‘behaviour management plan’. However, there was no evidence that the management plan in place had been agreed by other appropriate professionals, for example a representative of the intensive support team. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 14 Records seen and discussion with the manager confirmed that despite a recommendation made concerning residents finances following the last inspection the manager continued to act as the appointee for all residents and was the sole signatory on their building society accounts. The inspector also noticed that while records of all financial transactions were held they were not independently audited. Records also evidenced that the home holds cash on behalf of residents. On the day of inspection cash held was locked away but staff confirmed that the home did not have the facility of a safe. Furthermore the procedures in place for handling residents money was dated 1997 with no evidence that procedures had been reviewed since that time. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 15 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, 28 & 30. Residents can expect to live in a clean and comfortable environment. Furthermore, they can expect to have a room of their own that reflects their needs and interests. EVIDENCE: The home is spacious and simple in design and layout. Communal areas included a lounge, dining room, kitchen, small ‘relaxation’ room, bathroom and shower room. All areas had appropriate facilities and were furnished with comfortable ‘domestic’ type furniture. There was also a small office that ‘doubled up’ as a staff sleep in room. Although generally well decorated some areas in the hall and dining room were ‘scuffed’ and needed attention. All residents had their own single bedrooms. Three of the four bedrooms were seen and each was decorated in a way that reflected the resident’s personalities and interests. All were individually furnished and personalised with their own belongings. Since the last inspection a hand basin had been fitted in the laundry area. Appropriate laundry facilities were in place and liquid soap and paper towels were readily available for staff use. The laundry room also contained a locked cupboard for the safe storage of Substances Hazardous to Health. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 16 The bolt at the top of the front door had been removed since the last inspection and the area was now fitted with an alarm system. On the day of inspection all areas seen were clean and odour free. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 35 & 36. Residents can expect to be supported by appropriate ratios of care staff but they cannot be certain that those staff are appropriately qualified. EVIDENCE: On the day of inspection there was four care workers on duty. One was allocated shift leader in the absence of the manager and another was rota’d specifically to work on a 1-1 basis with a specific resident. This corresponded with the staff rota that had been developed since the previous inspection to include the part time cleaner. Staff spoken with also confirmed that agency staff continued to be used on a regular basis to ensure adequate numbers were always on duty. They estimated that the average number of shifts currently covered by agency staff was 3-4 a week. Standards relating to the recruitment of staff and staff development and training were not assessed in any detail at this inspection as; due to the absence of the manager, staff records were unavailable for inspection. However, staff spoken with confirmed that they had undertaken appropriate induction programmes. At the end of the day the manager also reported that two staff had now completed NVQ level two training and another three care staff were due to start the qualification in the near future. However, there was no supporting evidence to confirm this. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 18 Staff spoken with and records seen evidenced that the manager had planned 1-1 supervisions with staff. With the exception of one care worker records indicated that the frequency of supervisions was in accordance with good practice guidelines of at least six times a year. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 40, 41, 42 & 43. Residents cannot be certain that their rights and best interests are safeguarded by the homes polices and procedures. EVIDENCE: The home had a wide range of policies and procedures in place but with the absence of the manager staff on duty were not always able to easily identify where they were kept. Furthermore, policies seen were not always up to date and current. However, since the last inspection the home had put a procedure in place for dealing with foul laundry. The home had appropriate records in place including accident/incident records and fire safety records. However there was no evidence that the records of incidents/accidents were used to appropriately monitor occurrences. Fire records indicated that appropriate procedures were in place including regular servicing of equipment with the exception of fire extinguishers that had not been serviced since 2004. The inspector also noticed that both extinguishers in Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 20 the hall and kitchen were ‘sitting’ on the floor and had not been fitted to the wall with their brackets. Records held in the kitchen to monitor the temperature of the fridge and freezer evidenced that the home had not monitored them on a daily basis. Residents records were held on shelves in the office and were not held securely, further more staff spoken with indicated that there has been at least one instance when staff records have not been appropriately ‘locked away’. Staff spoken with indicated that there were issues of conflict within the team and the moral amongst the staff group seemed ‘low’. They reported that a staff meeting had been arranged for later in the week in an effort to try to identify and resolve some of the issues. Later, the area manager confirmed that he had in fact received a serious complaint earlier in the day. The nature of the complaint and the area manager’s response was discussed in detail. The matters raised would be investigated in accordance with the homes disciplinary guidelines and with the guidance of statutory authorities as appropriate. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 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 X 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 2 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 3 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 X X X 2 2 2 3 Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 22 Are there any outstanding requirements from the last inspection? No 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 YA9YA6 Regulation 12(1) 13(4) 15(2)(b) 13(6) Requirement The Registered Person must ensure that residents care plans and risk assessments are regularly reviewed and updated as appropriate. The Registered Person must ensure that the Policies and Procedures in place for the safe handling of service users monies comply with current good practice guidelines. The Registered Person must ensure that the Behaviour Management Plan in place for the named resident is agreed with and signed by appropriate professionals/representatives. The Registered Person must ensure that all care staff receive adult protection training and are familiar with local authority procedures. The Registered Person must ensure that the home has appropriate written policies and procedures in place and that they are ‘current’, ‘up-to-date’ and comply with current legislation. DS0000024412.V285390.R01.S.doc Timescale for action 31/05/06 2 YA23 31/05/06 3 YA23 13(6) 30/04/06 4 YA23 13(6) 30/06/06 5 YA40 12 13 30/06/06 Henry Street Residential Home Version 5.1 Page 23 6 YA41 17(1)(b) 7 8 YA42 YA42 12 13 12 13 The Registered Person must 30/04/06 ensure that records are held securely and in accordance with the Data Protection Act1998. The Registered Person must 31/03/06 ensure that food hygiene guidelines are adhered to. The Registered Person must 28/02/06 ensure that the homes fire extinguishers are appropriately ‘fitted’ and serviced on an annual basis. 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 YA23 Good Practice Recommendations There should be a safe installed to appropriately safeguard resident’s money. Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Suffolk Area Office St Vincent House Cutler Street Ipswich Suffolk IP1 1UQ 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 Henry Street Residential Home DS0000024412.V285390.R01.S.doc Version 5.1 Page 25 - 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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