Inspection on 26/04/05 for Hough Top

This inspection was carried out on 26th April 2005.

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

Hough Top 04/01/07

Hough Top 31/08/05

Hough Top 11/01/05

Hough Top 13/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Hough Top 7 Hough Top Leeds West Yorkshire LS13 4QW Lead Inspector Chris Levi Unannounced 26th April 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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. Hough Top Version 1.10 Page 3 SERVICE INFORMATION Name of service Hough Top Address 7 Hough Top, Leeds, West Yorkshire, LS13 4QW Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 204 0155 0113 204 0155 TACT Mrs Hilda Margaret Hurren CRH 4 Category(ies) of LD4 registration, with number of places Hough Top Version 1.10 Page 4 SERVICE INFORMATION Conditions of registration: none Date of last inspection 11th & 14th January 2005 Brief Description of the Service: The home is located in the residential area of Swinnow in Leeds not far from Pudsey. It is within easy walking distance of a local parade of shops that includes a post office. Service users use these facilities on a regular basis. The home has a car that is well utilised to transport service users to appointments and trips out. A regular bus service is available to travel into the city centre or further afield.Personal care is provided for up to four service users who have learning disabilities. All are currently below the age of 65 years. Nursing care is not provided and the home is supported by local health care services.Accommodation is domestic in style. The home is situated in a quiet street in a residential area. The home is located on two floors and service user bedrooms are situated on the ground floor. They are all single rooms, comfortable and well decorated in the personal style of the individual. There are large enclosed gardens to the rear of the house with a small patio area. Hough Top Version 1.10 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced. It started at 9.30am finishing at 3pm. The person in charge of the home was Donnett Larkins a senior support worker. Most of the day was spent with the four service users and two staff asking their views on standards of care at the home. A number of documents were inspected. These included plans of care for service users, management of medication, records of meetings for both staff and service users. A number of maintenance and health and safety documentation were also looked at. Some areas of the premises were visited. The men all under the age of 65 years living at the home liked to be referred to as service users. Information about the inspection findings was given to Ms Larkins at the end of the inspection. Requirements identified during the inspection can be found at the back of the report. What the service does well: 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 full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Hough Top Version 1.10 Page 6 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 Standards Statutory Requirements Identified During the Inspection Hough Top Version 1.10 Page 7 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 standard(s) 1,2,5. People who use the service are able to access clear and accurate information about whether or not they wish to live in the home. Effective systems are in place to assess service user needs before admission to the home. Written contracts identifying the terms and conditions of a service users stay were incomplete. This may affect their rights of tenancy. EVIDENCE: The home has up to date written information about services provided at Hough Top. It is in a picture format as well as written text. This will assist any new service users who are unable to read to make a decision about moving to the home. Individual written contracts have been given to service users but have not been signed by their next of kin. None of the service users are able to understand or sign their own contracts of terms and conditions. The person in charge said the organisation, TACT, has a procedure for admission. This includes a number of informal visits and detailed assessments. However, as no new service user has been admitted to the home since1966, when the current service users moved in from a long stay hospital in Leeds, there was no documentation available to confirm this. Hough Top Version 1.10 Page 8 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 standard(s) 6,7,8,9. Service users are provided with opportunities to make decisions about the way they live their lives, taking into consideration risks, choice and benefit to the individual. This promotes individuality, involvement, and fulfilment for each service user. EVIDENCE: Detailed plans of care are in place to support each service user. Two looked at covered all aspects of the service users life and the help needed to achieve their personal goals. The service users meet for a group monthly meeting to agree any changes. Individual meetings are held monthly between service user and staff from the home and staff from external services. This provides opportunities to review and change any support offered to the service user. As the service users have very limited ability to speak, pictures are provided to help the service users make decisions about their life. A number of written risk assessments were seen to enable service users take risks in daily social activities. Hough Top Version 1.10 Page 9 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 standard(s) 11,12,13,14,15,16,17. Individual service users spend their day in the way they have chosen. They each appear to have busy, enjoyable lives assisted by staff, who offer support to maximise opportunities for a fulfilling life. Food served at the home is balanced and nutritious and enjoyed by the service users. EVIDENCE: Each service user has a detailed written plan for agreed activities both social and domestic. They are very comprehensive in range and chosen by the service user. They include dog walking at a local dog’s home, trampoline at a facility in Leeds, DIY at a local centre and regular trips to pubs, and cinemas. Their day is structured, busy, and achievable as the home has its own transport. Sometimes these activities have to be changed if insufficient staff are on duty. All the service users except one have family who are kept informed of the wellbeing of their relative. Letters sent to them were seen. Very few are able to visit on a regular basis. An advocate should be available for the service user without family. Hough Top Version 1.10 Page 10 Support staff, with the assistance of one service user, purchase food from the supermarket. Likes and dislikes and dietary needs are taken into account when the weekly menu is prepared. On the day of the inspection it was fish and chips, enjoyed by all, from the local shop, because workmen were relaying new flooring in the kitchen and bathroom. A dietician was consulted for one service user and suggestions for appropriate food has been introduced. A risk assessment is missing for one service user at risk from choking. Staff said they encouraged service users to eat fresh fruit and vegetables on a daily basis. Hough Top Version 1.10 Page 11 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 standard(s) 18,19, 20,21. Service users plans provide good information to ensure their health and wellbeing needs are met. Some improvement has taken place in the administration of medication to service users. EVIDENCE: The care plans looked at contained relevant, detailed information about the personal and health care needs of the individual service user. External health professional contribute where necessary. This was seen in documentation and confirmed by staff, who said she valued the information and support offered by specialist health professionals. The plans are reviewed on a monthly basis and when necessary, and the service user is involved in the reviews. No service user is able to self medicate. TACT, the organisation that manages Hough Top, has recently revised the policy and procedures for managing service users medication as in the past unacceptable levels of errors have occurred. The new procedure appears to have reduced, but not eliminated the number of errors in the past, by some staff when administering medication. All staff who administer medication had received additional training. Good practice was Hough Top Version 1.10 Page 12 observed during the inspection. No errors were noted on the medicine record sheets. It was recommended that this document be taken to the place where medication is administered, to avoid the chance of staff forgetting to sign the sheet. The medicine cabinet key should stored more securely to ensure safe storage of medicines. Information relating to the final illness and death of a service user is now recorded. Hough Top Version 1.10 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 standard(s) 22,23. Systems are in place to protect service users from abuse, and encourage their relatives to make complaints on behalf of the service users. EVIDENCE: The complaints procedure is displayed in the hallway. No complaint has been recorded since the last inspection. The home has a written procedure on what to do in the event of an allegation of abuse. It was clear and easy to follow. The senior on duty confirmed she understood the term whistle blowing and both staff have attended training on recognising the different types of abuse. Hough Top Version 1.10 Page 14 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 standard(s) 24,28,30. Service users are provided with a safe and homely environment where individual service users can move freely about the house. Further research by TACT to provide staff with a device to call for help in an emergency must continue. EVIDENCE: The environment is homely. The lounge and dining room is furnished in a modern style with access to the well-used garden. The front door has a coded entry system to prevent service users leaving the home unaccompanied. Service users bedrooms are suitable to meet their individual needs and full of their special belongings. The building is owned and managed by a housing association that have responsibilities for building refurbishment and repair. The senior support worker said they provided a good and fairly prompt service. There is no mechanical system in place to alert staff of an emergency situation. This situation is being reviewed by TACT in all homes. During the inspection contractors were fitting new flooring to the kitchen and bathroom. Staff worked hard to ensure this caused as little disruption as Hough Top Version 1.10 Page 15 possible to the service users. Staff do all the cleaning tasks within the home and there was evidence that they try to involve the service users. The home was clean, tidy free from odour and no health and safety hazards were noticed. Hough Top Version 1.10 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,35,36 The staff team at Hough Top are well trained and supported to provide very good levels of support to service users. EVIDENCE: Service users benefit from the home being fully staffed. It was noted and confirmed by staff that staff shortages reduce the quantity and quality of individual service user activities. On the morning of the inspection, staff numbers were reduced by one support worker, due to sickness. The senior had made a judgement that it would be better to work with two on the shift rather than use agency staff, who do not know the service users. The full complement of staff was on duty for the late shift. Staff are employed for a mixture of night and day shifts. This provides service users with a known support worker 24hours a day and promotes continuity of care. The staff on duty were clear on their roles and responsibilities throughout the shift. It was pleasing to note that the service users needs were always put first, other jobs had to wait. Staff recruitment documentation was not available, the acting manager was not on duty during the inspection, only she can access this information. As a result, a previous requirement to demonstrate safe recruitment of staff remains. However, the senior support worker said a new member of staff due Hough Top Version 1.10 Page 17 to start work this week had been delayed because the necessary checks had not been completed. One support worker provided written information to confirm that she has attended “lots of training” provided by TACT. She has achieved NVQ level 2. Both members of staff said they had opportunities to discuss training needs in one to one supervision sessions, and staff meetings held monthly. A refresher session for moving and handling training is required for both members of staff. Hough Top Version 1.10 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,39,42,43. Despite profound learning disabilities affecting service users ability to speak, the management and staff use their knowledge and understanding of the service users to achieve a safe, well run, person centred service. EVIDENCE: Regular meetings are held to review services provided and explore new opportunities for individual service users. The key worker system works well. This was confirmed by written information and conversations with staff. Health and safety in the workplace is the responsibility of all staff. A record of regular checks on the safety of the building and equipment was seen. A senior management team supports the acting manager. They visit the home on a regular basis. The regulation 26 visit reports sent to the CSCI inspector are valued to inform future inspections. The home has documentation that is held in a variety of folders, files and books. Hough Top Version 1.10 Page 19 All of the information is relevant to support service users and staff. However, this did present the inspector with challenges trying to track service user information. Staff were confident about the systems in place. Some documents were repeated in different files, adding to the existing paperwork. Hough Top Version 1.10 Page 20 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 3 Standard No 37 38 39 40 41 42 43 Score 3 x 3 x x 3 3 Hough Top Version 1.10 Page 21 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. 4. Standard 5 20 24 34 Regulation 5 13.2 13 19 Requirement All service users or their representatives must sign the contract of terms and conditions Medication must be stored and administered safely. the providers must ensure staff are provided with a call system in the case of an emergency. the registered person must be able to evidence good recruitment practices.Staff must not commence employment until checking processes are complete. (previous timescaleof 28th February 2005 not met.) (evidence that this requirement had been met was not available for the inspection) Timescale for action 30th July 2005 30th June 2005 30th Sept 2005 30th May 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Hough Top Version 1.10 Page 22 Commission for Social Care Inspection Aire House Town Street Rodley LS13 1HP 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 Hough Top Version 1.10 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!