CARE HOME ADULTS 18-65
Heyhead House 1 Trinity Close Brierfield Lancashire BB9 5ED Lead Inspector
Mrs Julie Playfer Unannounced Inspection 7th February 2006 10:00 Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 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 Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 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. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Heyhead House Address 1 Trinity Close Brierfield Lancashire BB9 5ED 01282 617902 01282 617902 S.Brels@hotmail.com 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) Mr Shaun Martin Brelsford Mrs Amanda Jane Brelsford Miss Rachael Elizabeth Simpson Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The home should be staffed as follows: Waking Day 7:30 am - 10:00pm Care Staff - 2 staff 8:00 am - 9:30am 1 staff 9:30 am - 4:00pm 2 staff 4:00 pm - 10:00 pm At weekends or whenever there are more than 6 service users at home 2 care staff should be on duty at all times. 2. 3. 4. Night Time - Care staff 2 staff sleeping in No more than one wheelchair user may be accommodated in the home. The service must employ a suitably qualified and experienced manager, who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 8 service users in the category of Learning Disability 4th May 2005 Date of last inspection Brief Description of the Service: Heyhead House is registered with Commission for Social Care Inspection to provide accommodation and personal care for eight adults (aged 18-65 years) with a Learning Disability. The home is a purpose built single storey building, providing accommodation in eight single rooms, two of which have an ensuite facility, comprising of a toilet and hand wash basin. The shared space is provided in a lounge and dining room. The home is located approximately half a mile from Brierfield town centre. There is a garden and patio area surrounding the property and small car park at the front of the building. The staffing levels form part of the conditions of registration. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place at Heyhead House over six hours on 7th February 2006. The previous inspection was carried out on 4th May 2005. No additional visits have been made to the home since the last inspection. The purpose of this inspection was to assess important areas of life in the home and check the progress made to meet previous requirements and good practice recommendations. On the day of inspection there were 8 residents accommodated in the home. Information was obtained from care records, staff records and policies and procedures. The inspector also spoke to the residents, the staff on duty, and the registered manager. A partial tour of the premises was also undertaken. What the service does well: What has improved since the last inspection?
Since the last inspection the service users guide had been updated to make some of the information easier to read and understand. A new care plan format had been introduced which covered the residents’ needs in respect to their personal, social and healthcare needs. The plans also included clear guidance to staff on how to meet these needs. The risk Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 6 assessments had been revised to incorporate details about how to minimise the potential risk or hazard. A record had been maintained of medication received into the home. This meant an audit trail could be traced of all medication entering, administered and leaving the home. Two new settees had been purchased for the living area. The settees provided extra seating space to enable more people to sit comfortably in the lounge. A new television with “freeview” and a DVD player had also been installed in the lounge. The registered manager had established a programme to supervise the staff at least six times a year. The supervisions enabled the staff to talk about their work and identify future training needs. Progress had been made to develop the quality assurance system to ensure the residents’ views underpinned the future plans for the home. What they could do better: Please contact the provider for advice of actions taken in response to this inspection.
Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 8 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 Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 9 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): 1, 2 and 5 Residents were provided with useful and informative information about the services and facilities provided in the home. Resident’s needs were properly assessed and reviewed. EVIDENCE: Written information about the home in the form of a statement of purpose and service users guide was available for service users. The service users guide had been distributed to all residents. Since the last inspection the guide had been updated and part of the documentation had been produced in a pictorial format. There had been no residents admitted to the home since the last visit. However, it was evident from the case tracking process that a full assessment of needs had been carried out prior to admission for existing residents. The assessments had been carried out by the social worker. All residents had been issued with a contract, which explained the terms and conditions of residence in the home. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 8 and 9 The care planning system addressed the needs of the residents and provided guidance to staff on how these needs were to be met. Relationships within the home were good. The established consultation arrangements ensured residents were able to participate in all aspects of life in the home. EVIDENCE: Since the last inspection the care plan format had been revised and improved. From the case files seen, it was evident each resident had a plan of care, based on the assessment of needs. The plans set out in detail the action needed to be taken by staff to ensure all needs were met. However, it was evident that not all plans had been reviewed every six months. The residents were involved in the care planning process and had signed the plans to indicate their involvement and agreement. It was the practice of the home to support responsible risk taking and policies stated that the role of staff was to facilitate independence wherever possible. Since the last inspection the risk assessments had been revised to include risk management strategies.
Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 11 During discussion with the residents, they confirmed they were consulted and were able to participate in life in the home. As such the residents contributed to general household tasks, which included cooking and cleaning. A rota of “jobs” for instance washing up was displayed in the kitchen to ensure the distribution of tasks was equitable. Resident’s meetings were arranged on a frequent basis and residents were encouraged to express their views on all aspects of life in the home. The residents were also able to participate in a section of the staff meeting, when the minutes of the resident’s meetings were discussed. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 and 17 Residents were provided with good opportunities to engage in a range of appropriate activities and were supported to use community facilities. The residents maintained strong links with their families and enjoyed positive relationships within the home. Arrangements were in place to ensure the residents participated in the life of the home and their rights were respected. EVIDENCE: The residents spoken to said they enjoyed attending college and found their courses interesting. The residents attended different courses in line with their interests, which gave them the opportunity to meet people outside the home environment. Three of the residents also attended a local youth and community centre. The residents enjoyed using leisure facilities in the local area, which included the pub, cinema and restaurants. One resident spoke about going to a nearby church and said she enjoyed participating in the church activities. Since the last inspection the residents had been away on holiday for five days to Blackpool, in two separate groups.
Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 13 Families and friends were able to visit the home at any time and some residents enjoyed regular visits to their parent’s house. These relationships were supported by the registered manager and staff and transport was provided as necessary, in order to facilitate the visits. The residents said the routines in the house were flexible and were designed around their arrangements for the day. As such, there were different routines at the weekend. The menu was compiled on a weekly basis and residents were able to contribute to this process. There was a choice of meal and residents were able to participate in the preparing, cooking and serving of food. The inspector observed staff asking residents about their choice of food and snacks throughout the visit to the home. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Personal support was provided in a manner, which respected the residents’ rights to privacy and dignity. Healthcare needs were assessed and recognised. To minimise potential risks to residents some practices and record keeping in respect to medication must be improved. EVIDENCE: The residents’ individual care plans set out the personal support each resident required and provided details of how this support was to be delivered. Residents spoken to confirmed personal support was provided in private and their rights to privacy and dignity were respected. The registered manager and staff ensured consistency and continuity for residents by the use of a key worker system. A record was also maintained of individual likes and dislikes as part of the assessment and care planning processes. Healthcare needs were appropriately assessed and were included in the care plan. There was evidence to indicate the residents had access to NHS services and the advice of specialist services had been sought as necessary. However, the resident’s weight was not recorded for monitoring purposes. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 15 The home operated a monitored dosage system for the administration of medication, which was dispensed into blister packs. There were appropriate policies and procedures in place for the receipt, administration and disposal of medicines and since the last inspection a record had been maintained of all medication received into the home. However, not all prescribed medication was entered onto the medication administration record, some prescribed cream had not been administered in line with the prescriber’s instructions and a protocol was not in place for all variable dose medication. In addition, the medication administration record did not include instructions for the application of medicated creams, transcribing from prescription labels onto the medication administration record had not been witnessed by two members of staff and not all staff designated to administer medication had received accredited training. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Systems were in place to ensure any concerns of residents would be acted upon. Appropriate policies and procedures were available to respond to any allegations or suspicions of abuse. EVIDENCE: Both informal and formal arrangements were in place for the registered manager and staff listen to and act on the views and concerns of residents. This was achieved during daily conversation, one to one discussion with residents and their key workers and residents’ meetings. The complaints procedure was included in the service users guide and was displayed in the hallway. A pictorial version of the procedure was also available and displayed. The registered manager had not received any complaints since the last inspection. There was an appropriate procedure for responding to any suspicions or allegations of abuse. Staff had also received in-house training on the protection of vulnerable adults, which included a video and questionnaire. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 The residents were able to personalise their bedrooms and create an individual space suitable for their needs. Improvements must be made in some areas of the home to ensure the residents live in a homely, comfortable and safe environment. EVIDENCE: Heyhead House is a purpose built property, providing accommodation for eight residents. All bedrooms are single occupancy. Communal space is provided in a lounge and dining room. There is also space in the kitchen to eat meals. There are the necessary number of toilets and bathrooms and one assisted shower. Since the last inspection a new washer and dryer had been installed as well as a new television along with a “freeview” box and DVD player. The bedrooms are all at ground floor level and have been decorated according to the personal preferences of the residents. Many of the residents had personalised their rooms with posters and other meaningful possessions. Access for one resident who uses a wheelchair was provided by a ramp to the front door. The home also had the necessary moving and handling equipment. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 18 Since the last inspection, it was noted that the two pieces of wood had been removed from the corridor and replaced by one piece of wood/plastic, however, the screws holding this to the floor were raised from the surface. Two new settees had been purchased for the living room, which provided additional seating space. However one armchair had not been replaced. The fabric of the arm of this chair was worn such that the foam was exposed in at least one area. The walls in bedroom 3 were damaged with areas where the paint had been removed. The home was clean and hygienic in all areas seen. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 19 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): 31, 32, 33, 34, 35 and 36 The residents benefited from well supported and supervised staff, who were in sufficient numbers to meet the needs of the residents. However, elements of the staff recruitment process must be improved to minimise potential risks to residents. EVIDENCE: Staff were issued with job descriptions, which set out their roles and responsibilities. It was evident the job descriptions were linked to meeting the needs of the residents. From discussions with staff and registered manager during the inspection, it was evident they had a good understanding of the residents’ needs and knew the residents well. Staff referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. The staff rotas indicated that the staffing levels were in line with the conditions of registration and additional staff were placed on duty, where necessary, to meet the needs of the residents. The files of three members of staff who had commenced working in the home since the last visit were viewed during the inspection. It was noted that the staff had completed an application form and had attended the home for an interview. However, there were shortfalls in the recruitment process which
Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 20 included gaps in employment history, one reference being sought from a relative and only one reference in place at the time one member of staff started working in the home. Satisfactory police checks had been carried out for all three applicants. There was evidence on the staff files to indicate staff had completed an in house induction and “Skills for Care” (formerly TOPSS) induction within six weeks of employment. Staff had been supplied with a staff handbook, containing pertinent policies and procedures. A training and development plan and individual training assessments and profiles were seen. At the time of the inspection 3 members of staff had completed NVQ level 2 or above, this equated to 33 of the care staff. Since the last inspection the registered manager had established a programme to ensure all staff received supervision six times a year. Staff had an annual appraisal during 2005. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 21 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): 37, 38, 39, 42 and 43 The management approach promoted positive relationships between the staff and the residents and the overall atmosphere was open and friendly. The improvements made to the quality assurance systems ensured the residents’ views underpinned the development of the home. Some health and safety issues must be attended to in order to minimise potential risks to residents. EVIDENCE: Since the last inspection a manager has been registered for the home. The registered manager has several years experience of caring for adults with a learning disability and had achieved the Registered Manager’s Award. At the time of the inspection the registered manager was working towards NVQ level 4 in care and anticipated completing this qualification in Autumn 2006. There were systems in place to brief staff, including staff meetings. The staff meetings were held on a regular basis and the minutes of recent meetings were seen during the inspection. Relationships within the home were positive and the staff spoke about the residents with respect.
Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 22 The home was accredited with a post recognition Investor’s in People Award in April 2005. The registered manager had maintained an audit of the care plans and the environment and had carried out a satisfaction survey of the residents, relatives and professional staff. The results of the surveys had been collated and a development plan had been produced. The home had a full set of policies and procedures relating to health and safety and staff records demonstrated that the staff had received appropriate health and safety training including moving and handling and first aid. However, it was noted the electrical safety certificate relating to the whole building had recently expired and there was no recent documentation relating to the testing of the fire system. It was also apparent that the hazardous substances were not stored in a secure location. There was appropriate insurance cover in place against the loss or damage to the assets of the business and business interruption costs up to a minimum of £5 million. There was no financial plan available. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 23 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 X 3 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 2 2 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 2 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Heyhead House Score 3 2 2 X Standard No 37 38 39 40 41 42 43 Score 2 3 3 X X 2 2 DS0000009634.V272237.R01.S.doc Version 5.0 Page 24 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. 2. 3. Standard YA6 YA20 YA20 Regulation 15 13 13 Requirement The care plans must be reviewed at least every six months or in line with any changing needs. All prescribed medication must be entered onto the medication administration record. Instructions for the application of prescribed creams must be included on the medication administration record. All medication including prescribed creams must be administered in line with the prescribers instructions. (Previous timescale of 04/05/05 – not met). The armchair in the living room must be recovered in a fabric, which meets fire regulations or be replaced. The damaged walls and paintwork in room 3 must be repaired and repainted. The screws securing the piece of wood/plastic must be flush to the surface. The registered person must ensure the electrical safety systems and fire systems are tested and serviced as
DS0000009634.V272237.R01.S.doc Timescale for action 01/04/06 07/02/06 07/02/06 4 YA20 13 07/02/06 5. YA24 16 01/04/06 6. 7. 8. YA25 YA26 YA42 23 13 13 (4), 23 (4) 01/04/06 07/02/06 20/03/06 Heyhead House Version 5.0 Page 25 9. YA42 13 (4) appropriate and send a copy of the certificates to the Commission. If this work has already taken place evidence must be forwarded to the Commission. All hazardous substances must be stored in a secure location. 20/03/06 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. 2. 3. 4. 5. 6. 7. Refer to Standard YA19 YA20 YA20 YA20 YA32 YA37 YA43 Good Practice Recommendations The resident’s weight should be monitored and recorded. All staff medication training should be accredited. All transcribing from prescription labels to the medication administration record should be signed and witnessed by two members of staff. A protocol should be devised for all variable dose medication. 50 of the care staff should achieve a National Vocational Qualification level 2 in care by 2005. The registered manager should complete NVQ level 4 in care. The registered person should devise a financial plan. Heyhead House DS0000009634.V272237.R01.S.doc Version 5.0 Page 26 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
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