Inspection on 25/07/07 for Hexthorpe House

This inspection was carried out on 25th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

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Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

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Pennine Camphill

Whitwood House

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

CARE HOME ADULTS 18-65 Hexthorpe House 31 Spansyke Street Hexthorpe Doncaster South Yorkshire DN2 6AD Lead Inspector Valerie Hoyle Key Unannounced Inspection 25th July 2007 10:00 Hexthorpe House DS0000069432.V346652.R01.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 Hexthorpe House DS0000069432.V346652.R01.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. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Hexthorpe House Address 31 Spansyke Street Hexthorpe Doncaster South Yorkshire DN2 6AD 01302 363674 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) Active Care Homes Ltd Post Vacant Care Home 1 Category(ies) of Learning disability (1) registration, with number of places Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection New registration Brief Description of the Service: Hexthorpe House is a mid-terrace house on a residential street in Hexthorpe near the town of Doncaster. The home provides care for one person with a learning disability aged between 18–65 years. The home has two bedrooms, although one bedroom is used as a dressing room for the service user. There are two reception rooms and an open plan kitchen. The fees for the home are £3,700 per week with additional charges includes toiletries and activities. The manager has completed the pre-inspection questionnaire, and the Statement of Purpose and Service User Guide was available for inspection. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection of the registered service, which looked at all standards to assess the quality of outcomes for the one person who lives at the home. The inspection took place over 3 hours, and the person who lived at the home did not want the inspector to look around, therefore staff assisted with providing information about the environment. The inspector spoke to the two registered providers, the manager, and the person who uses the service to make a judgement about the care provided. A number of records were examined these included medication; the persons care plans, recruitment, training, quality assurance systems, and health and safety records. Three ‘have your say…’ surveys were received from the person who uses the service, a staff member and a health care professional, their comments are included in this report. The inspector wishes to thank the registered providers, manager (who has submitted an application to Commission for Social Care Inspection to be the registered manager), staff, service user for their assistance and co-operation. What the service does well: What has improved since the last inspection? This was the first inspection of the service. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Hexthorpe House DS0000069432.V346652.R01.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 Hexthorpe House DS0000069432.V346652.R01.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, 3, 4 and 5. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Comprehensive information was provided to the person including what can be expected from the service. People who use the service were assessed before moving into the home to ensure their needs can be met. EVIDENCE: There was a Statement of Purpose and Service User Guide, which provided information to the person who lives at the home. The information was written in a format, which included pictures, to assist people with a learning disability to understand what they could expect from the service. Comprehensive assessments had been undertaken by the registered providers prior to the person’s admission to the home. The assessments were completed over a numbers visits as the person had moved from long-term (hospital) care settings into their accommodation. The person had been provided with a statement of terms a conditions/contract that set out the details of the care provided. It included the fees and the role and responsibility of the registered providers. The registered provider said the Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 9 contract had not been signed due to the anxiety and mental health of the person who lives at the home. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 10 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, 8, 9 and 10. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home promotes philosophies to enable the person at the home to meet their full potential, with sufficient care plan instructions and comprehensive risk assessments to maximise their safety and protection. EVIDENCE: The care plan examined was person centred and included comprehensive behaviour protocols to enable staff to support the person who lives at the home. Risk assessments are reviewed regularly and community nurses provide support to help maintain the persons mental healthcare needs. The person was fully involved in developing the care plan and is confident that staff will maintain confidentiality of information recorded. The home had developed and implemented protocols in the event of the person going missing from the home, this ensures the person remains safe and protected. Because the person has high support needs, two staff provide support during the day, Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 11 and one staff works nights. The team works consistently to ensure the person understands how their actions will be responded to. The manager and staff support the person to manage their personal money. Daily financial records were examined which show the person is given a set amount of money, to encourage the person to budget for items they want to purchase. The person said they were saving up to buy new clothing. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 12 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): 11,12, 13, 14, 15, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are able to make decisions and choices about their lifestyle and are supported by staff to develop new skills. EVIDENCE: The person centred plan provides information about supporting the person to take part in daily tasks within the home. It is clear from the information that staff are clear about how to encourage involvement in the tasks and the intervention needed if the person displays inappropriate behaviour. The person understands the importance of ‘time out’ in their bedroom to help to reduce their anxiety. The manager said the person had been consulted about interests and lifestyles, although decisions to take part in activities would only be made at short notice Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 13 to minimize distress to the person. Activities include weekly grocery shopping, trips to Yorkshire outlet and town centre shopping. The manager said the persons diet had improved since their admission into the home. A varied diet is encouraged and the person is encouraged to help with the preparation of meals. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 14 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 and 21. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Health care needs of the person were met and personal support was provided in the way the persons prefer. EVIDENCE: Staff support the person in a sensitive way to encourage the person to by their own clothing and personal items. The person said they had been saving their money to by some new jeans and training shoes from town. The person was supported to attend appointments with consultants, to ensure their mental health needs are met. Community nurses also support staff by visiting the person on a regular basis. A survey received from a healthcare professional said staff were very good at recognising when the person needed extra support to maintain their wellbeing. The manager said the persons healthcare plan identified protocols to minimize distress to the person prior to attending any health appointments. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 15 Medication polices and procedures in the home were very good, all medication was documented on arrival, and was documented when administered and disposed of. Medication was appropriately stored. All staff that administer medication had successfully completed accredited medication training to protect the person who lives at the home. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 16 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): 22and 23. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The home had a good complaints procedure and robust procedures to protect the person from abuse. EVIDENCE: There was a clear and effective complaints procedure, which includes set timescales. The complaints procedure also states that the Commission for Social Care Inspection can be contacted at any time. The home had received no complaints since it was registered. The home had a good adult protection policy that clearly defined different types of abuse and staff were well aware of this, they were also aware of the importance of whistle blowing. The Doncaster council policy for protection of vulnerable adults was also available in the home. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 17 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, 26, 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The person who uses the service were provided with a clean, comfortable environment to live in, which was well-maintained and encourages independence. EVIDENCE: The home is suitable for its stated purpose it is safe and comfortable, the manager said the person had only minimum furniture in the bedroom as the person found it difficult to cope with the usual items found in the room. The agreement was clearly recorded in the persons care plan. A second bedroom has been turned into a dressing room for the person. The inspector was not invited to look around by the person living at the home, although areas on the ground floor were clean and well maintained. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 18 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): 31, 32, 33, 34, 35 and 36. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People who use the service are protected by robust recruitment procedures. Staff had the skills and knowledge to ensure the person is cared for. EVIDENCE: A small team of staff provides support to the person who lives at the home. Most staff had worked at the home since its registration earlier in this year. Rotas were examined and they show that two staff support the person throughout the day. The home operated a thorough recruitment process. A selection of personnel files were looked at, they all contained all the required information and checks to ensure the person is protected. All staff had a clearly defined job description, signed and placed in their personal files. A selection of staff training files were seen, records were good and all training had been carried out to ensure the person’s needs are met. The manager had also implemented a rolling programme of training to ensure staff were Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 19 regularly updated, to ensure the persons needs were met by appropriately trained staff. Two staff had accessed LDAF (Learning disability award framework accredited training) while three staff had attained NVQ level 2 qualifications, and were now working towards NVQ Level 3. Regular staff meetings take place to ensure staff have the opportunity to discuss developing the service, and issues relating to the person who lives at the home. The survey received from a staff member confirmed that staff are encouraged to give their opinions about the service. Staff said they felt valued and supported. There was an induction programme, although it did not meet the ‘Skills for Care’ inductions standards. The registered providers said they intended to introduce a new programme for all new staff employed in the future. The staff had regular supervision to ensure they were competent to carry out their jobs and records of these were seen in the files. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 20 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, 38, 39, 40, 41, 42 and 43. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The health, safety and management arrangements are sufficiently robust to ensure the safety and protection of people who live at the home. People’s views are actively sought to improve the service. EVIDENCE: The manager has a wealth of experience and knowledge and was able to demonstrate her ability to manage the home. She has submitted her application to CSCI to be the registered manager, and intends to undertake the Registered Managers Award (RMA) commencing in August 2007. The registered providers said they gain the views of the people who use the service, and use a newsletter to publicise the results of surveys. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 21 Records were appropriately stored to maintain confidentiality, and the person said they were aware that staff recorded information about them. The maintenance records for electrical safety, portable appliance testing, legionella, and gas were all provided when the home was registered ensuring the safety of the service users. Fire checks, water temperatures and environmental safety checks including equipment and machinery were seen during the inspection, all were satisfactory. Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 22 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 3 4 3 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 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 2 3 3 3 3 3 3 Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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. 2. Standard YA35 YA37 Regulation 18 18 Requirement New staff must receive induction that meets the ‘Skills for Care’ induction standards. The registered manager must attain the RMA (Registered Managers Award) Timescale for action 01/10/07 01/02/08 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 Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Sheffield Area Office Ground Floor, Unit 3 Waterside Court Bold Street Sheffield S9 2LR National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Text phone: 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. Extracts may not be used or reproduced without the express permission of CSCI Hexthorpe House DS0000069432.V346652.R01.S.doc Version 5.2 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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