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Inspection on 12/01/06 for Huddersfield Mencap 4

Also see our care home review for Huddersfield Mencap 4 for more information

This inspection was carried out on 12th January 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 4 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The staff team continue to work hard to meet the needs of the residents. The residents spoken with said the staff care for them in their preferred way. The residents continue to receive the support they require to make decisions about their daily lives.

What has improved since the last inspection?

The manager and the staff at the home have worked hard to make improvements to the daily records kept for each resident. The daily records looked at reflected the individual residents plan of care. The manager is working towards making further improvements to the residents care records. There has been some redecoration to the communal areas of the home.

What the care home could do better:

The nutritional health care needs of the residents should be monitored with the appropriate action taken when required. The homes policy and procedure for medication must be followed consistently to ensure that the residents are protected by safe working practices. The organisation should develop a staff training and development programme to ensure that staff are appropriately trained to meet the needs of the residents.

CARE HOME ADULTS 18-65 Huddersfield Mencap 4 1 Victoria Road Lockwood Huddersfield West Yorkshire HD1 3TF Lead Inspector Bronwynn Bennett Unannounced Inspection 12th January 2006 08:45 Huddersfield Mencap 4 DS0000026344.V251255.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 Huddersfield Mencap 4 DS0000026344.V251255.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. Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Huddersfield Mencap 4 Address 1 Victoria Road Lockwood Huddersfield West Yorkshire HD1 3TF 01484 340833 01484 340833 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) Huddersfield Mencap Mrs Theresa Elizabeth Kelly Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th August 2005 Brief Description of the Service: 1 Victoria Road, Lockwood, is a care home providing personal care and accommodation for six people with learning disabilities. It is owned by Huddersfield Mencap, a charity providing a range of services locally for people with learning disabilities. The home is situated on the outskirts of an industrial/residential community close to the centre of Huddersfield. It was purpose built as part of a complex containing warden supervised accommodation for older people. The home is built on two floors with single rooms on both floors and adequate communal facilities. Huddersfield Mencap 4 DS0000026344.V251255.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, which took place on the 12th January 2006. The inspection was conducted over a four-hour period and included a tour of the home and the examination of files kept by the home. Some of residents and staff were spoken to. Not all the standards were assessed as many of the standards were assessed during the last inspection, which took place on 16th August 2005. What the service does well: What has improved since the last inspection? What they could do better: The nutritional health care needs of the residents should be monitored with the appropriate action taken when required. The homes policy and procedure for medication must be followed consistently to ensure that the residents are protected by safe working practices. The organisation should develop a staff training and development programme to ensure that staff are appropriately trained to meet the needs of the residents. Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 6 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. Huddersfield Mencap 4 DS0000026344.V251255.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 Huddersfield Mencap 4 DS0000026344.V251255.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. The individual needs of prospective residents are assessed. EVIDENCE: The home has worked well in assessing the potential needs of a resident prior to admission into the care home. However there is no organisational policy and procedure in place for admissions into the home and this should be addressed. Huddersfield Mencap 4 DS0000026344.V251255.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. The staff are working well with the residents to meet their individuals needs. EVIDENCE: Positive comments were received from two residents about the level of care and support they receive form staff. The care records were looked at for two residents. Generally the detail in these records is good. The care records continue to be well organised and easy to follow and there is evidence that the residents are involved in the care planning process. Some area of improvement is required regarding the information relating to the residents oral hygiene needs and this was discussed with the manager. A recommendation was made at the last inspection relating to the vagueness of some daily records, and this area has now been addressed. The manager has worked hard to make improvements in this area of individual care documentation. Huddersfield Mencap 4 DS0000026344.V251255.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): 16. The resident’s rights are recognised and respected. EVIDENCE: The residents spoken with said that the staff provide care and support in their preferred way. The staff were seen to have good relationships with the residents and the residents were referred to by their preferred name. Where residents have chosen to be responsible for any domestic tasks, this is recorded in their plan of care. Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 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 the following standard(s): 1819,20. The residents receive the care and support they require in the preferred way. There is a potential risk that some of the residents health and welfare needs are not been met. The homes policy and procedure for dealing with medication must be followed consistently in order to protect the residents. EVIDENCE: The staff were seen to be providing care and support to the residents in a sensitive and dignified manner. The residents said that they are able to choose times for getting up and going to bed and have a choice of food and can choose their preferred time for eating. The guidance and support that a resident may require is documented in their plan of care. The nutritional risk assessments looked at were up to date. One weight record showed that where there had been a significant weight loss no action had been taken. This issue was discussed at the last inspection and needs to be addressed. Accurate weight records should be kept for all the residents and suitable scales should be purchased for this purpose. Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 12 The medication records were examined for two residents and the majority of the medication could be reconciled with the records kept. The management of PRN (When required) medication requires improvement and the policy and procedure for the safe handling of all medication kept in the home must be followed consistently. The requirement made at the last inspection is carried forward. Huddersfield Mencap 4 DS0000026344.V251255.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): EVIDENCE: These standards were not assessed during this inspection however the complaints procedure displayed and the whistle blowing policy have been updated to include the information of how to contact the Commission for Social Care Inspection. Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 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 the following standard(s): 24. The residents live in a homely and safe environment that is generally clean and odour free. EVIDENCE: During this inspection the home was generally clean and odour free. There has been redecoration to some of the communal areas since the last inspection. The easy chair and sofas in the lounge are showing signs of wear and tear and should be replaced. A toilet seat and shower height adjuster in the identified bathroom is in need of replacement. Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 15 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): 32,34,35. The residents are supported by a competent staff team however staff training requires some development in order to ensure that staff are fully trained to do their jobs. Generally the residents are protected by the homes recruitment policy and procedure however these procedures should be further improved. EVIDENCE: One member of staff has achieved NVQ level 2 in care. There are no staff at the home currently working towards an NVQ qualification. The manager said that she supports the staff to gain knowledge and experience to appropriately meet the needs of the residents, and that the home has good support links with GP’s and other professionals. There was evidence that one member of staff had undertaken induction and foundation training. Four of the staff has completed LDAF (Learning Disability Award Framework) accredited training. There was no evidence of a training and development plan available during this inspection. Two staff files were audited. Generally the information held in these records was of a satisfactory standard. Improvements are still required regarding the information held in the staff records relating to the relevance of references and information relating to police checks and this was discussed with the manager. Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 16 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): 37,39,42. The resident’s benefit from a competent manager that is experienced and fit to run the care home. There is a quality monitoring system in place that seeks the views of the residents. The organisation must take steps to ensure the health, safety and welfare of the residents and the staff is promoted and protected. EVIDENCE: The manager Mrs Theresa Kelly is registered with the Commission for Social Care Inspection and has worked at the home since 1992. The manager had commenced NVQ level 4 training but due to unforeseen circumstances this training has stopped. The organisation must take action to address this matter. The last quality assurance report was made available during this inspection. The report seeks the views of the residents, staff and other stakeholders through questionnaires and consultation. The manager advised the inspector that a monthly audit of services is carried out at the home. Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 17 There was no evidence of any fire training being undertaken by the staff working at the home for over two years. Action must be taken to address this area of training. There were gaps in the records for the weekly testing of the homes fire alarm system. Urgent action is required by the manager in order to protect the residents. This area of concern was raised at the last inspection and a requirement was made regarding the matter, the requirement is carried forward. The hot water temperatures were checked and the readings were low. Hot water for bathing should be maintained at a temperature of close to 43 degrees centigrade. This issue was raised at the last inspection and action needs to be taken. Some staff require training in safe movement and handling techniques. A recommendation was made at the last inspection regarding this matter and is carried forward. Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 2 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 1 X 2 X 3 X X 1 X Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 19 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. Standard YA19 Regulation 12 (1) (a) Requirement The registered person shall promote and make proper provision for the health and welfare of the residents. Action must be taken when a resident has a significant weight loss. Timescale for action 12/02/06 2. YA20 13.2 3. YA42 13(4) 4. YA42 23 (4) (d) The policy and procedure for 12/02/06 medication must be followed to protect the residents. Previous timescale of 16/08/05 not met. The registered person shall make 12/02/06 arrangements for the regular testing of fire safety equipment Previous timescale of 16/08/05 not met. The registered person shall after 12/04/06 consultation with the fire authority make arrangements for persons working at the care home to receive suitable training in fire prevention. Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 20 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. Refer to Standard YA2 YA19 YA24 YA24 YA32 YA34 Good Practice Recommendations The organisation should develop a policy and procedure for the planned admission of residents into the care home. Suitable scales should be purchased to accurately record the weight of the residents. The easy chair and sofas in the lounge should be replaced. The toilet seat and showerhead adjuster in the identified bathroom should be replaced. The staff should undertake NVQ training. The organisation should seek to obtain references from the applicant’s previous caring roles where appropriate, in order to clarify the prospective employees suitability for the post. The organisation should develop a staff training and development programme to ensure the staff are appropriately trained to meet the needs of the residents The manager should complete the NVQ level 4 qualification. The hot water for bathing should be maintained at a suitable temperature of close to 43 degrees centigrade. Staff should complete annual movement and handling training. 7. 8. 9. 10. YA35 YA37 YA42 YA42 Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 21 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Huddersfield Mencap 4 DS0000026344.V251255.R01.S.doc Version 5.1 Page 22 - 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. 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