Inspection on 16/11/06 for Huddersfield Mencap 4

This inspection was carried out on 16th November 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Huddersfield Mencap 4 12/01/06

Huddersfield Mencap 4 16/08/05

Huddersfield Mencap 4 23/02/05

Huddersfield Mencap 4 23/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Huddersfield Mencap 4 1 Victoria Road Lockwood Huddersfield West Yorkshire HD1 3TF Lead Inspector Bronwynn Bennett Unannounced Inspection 16th November 2006 08:45 Huddersfield Mencap 4 DS0000026344.V311620.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 Huddersfield Mencap 4 DS0000026344.V311620.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. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Huddersfield Mencap 4 Address 1 Victoria Road Lockwood Huddersfield West Yorkshire HD1 3TF 01484 340833 01484 340833 linda.reilly@huddersfield-mencap.org.uk 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.V311620.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th January 2006 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 also containing warden supervised accommodation for older people. The home is built on two floors with single rooms on both floors and adequate communal facilities. The provider informed the Commission for Social Care Inspection on 26/09/06 that the fees are £525.00 per week Information about the home and the services provided are available from the home in the statement of purpose and the service user guide. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by the inspector. The visit began at 8.45am and finished at 1.50 pm. During this visit the inspector spoke to some service users, some of the staff and the home’s manager Ms Theresa Kelly. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the home. Prior to this visit the Commission for Social Care Inspection sent six questionnaires to service users living at Huddersfield Mencap 4. Six completed questionnaires were returned. There were six service users living at the home on the day of this visit. Surveys were sent to six service users’ relatives and four GPs. The inspector received responses from four relatives and two GPs. Other information used as part of this inspection process includes notifications from the home to the Commission for Social Care Inspection about deaths, illnesses, accidents and incidents at the home, and a pre inspection questionnaire was completed by the manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: The service users who responded to the survey said that they had received enough information about the home prior to moving in to Huddersfield Mencap 4. The home continues to work hard to support the service users. The care records show that service users are involved in the formulation and review of their care plan. It is good practice that the home has made the care plan available to service users in a suitable format. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 6 The service users continue to make decisions about their preferred lifestyle and are supported to be part of the local community. Positive comments were made about the staff in the surveys received by the Commission for Social Care Inspection. There is good interaction between service users and the staff. Service users were observed being treated in a dignified and respectful way. The service users are comfortable in raising any concerns or making a complaint. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 7 Service user surveys received said that they feel that the staff treat them well and the staff listen and act on what they say. The relatives and GPs commented that they are satisfied with the overall care provided in the home. What has improved since the last inspection? What they could do better: Greater care should be taken with the information contained in the staff records. A full employment history should be kept for all staff working in the care home. Greater care must be taken with the home’s medication policy and procedure. Suitable sit on weighing scales should be purchased so that all service users can be weighed in their own home. Please contact the provider for advice of actions taken in response to this Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 8 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. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 9 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.V311620.R01.S.doc Version 5.2 Page 10 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): 2 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Service users’ individual needs and aspirations are assessed prior to admission. EVIDENCE: There has been one admission to the home since the last visit by the Commission for Social Care Inspection. There was evidence available to show the needs and aspirations of the service user had been assessed. The service users responded to the survey and said they were asked if they wanted to move into the home. They also said they received enough information about the home prior to moving in. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 11 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 and 9 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The service users know that their assessed and personal needs and goals are recorded in their care plan. Service users are supported to make decisions in their lives. Generally service users are supported to take risks as part of an independent lifestyle. EVIDENCE: The Commission for Social Care Inspection received surveys from service users living at the home. All the respondents said they are treated well by the staff and their carers listen and act on what they say. Comments received from four relatives and two GP’s surveys said that they are satisfied with the overall care provided. As part of this visit to the home two service users care records were audited. The care records showed that all the service users had been involved in the Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 12 formulation and review of their care plan. Two service users spoken with said they had a key worker they liked. The home has worked hard to ensure the care plan is made available to service user in a language and format that they can understand. This is good practice and should continue. The detail in the care records continues to be good, well organised and easy to follow. However, greater care should be taken when a care plan is reviewed. Where a review shows a change to the care that is being given, such changes should be documented in the care plan. The Commission for Social Care Inspection received six service user surveys. The information from the survey showed that all the service users make decisions about what they do each day. The care records looked at showed where individual choices have been made. Service users are supported to manage their own finances should they wish to do so and lockable facilities are provided for this purpose. The care records audited held up to date risk assessments relating to any identified risks as part of an individual’s preferred lifestyle. The information recorded was easy to follow and clearly outlined the level of risk and the measures in place to minimise the risk and any associated hazards. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are supported to be part of the local community and take part in appropriate activities. Service users are supported to maintain relationships with family and friends. The service users’ rights are respected and individuals’ choice and independence is promoted. EVIDENCE: Service users living at the home have a care plan relating to work and educational activity. Some service users have paid jobs or are attending the local technical college. The service users are supported to be part of the local community. They have access to local facilities such as the church, pub, places of interest, walking trips and community day care. An annual holiday was organised this year and during this visit a service user said they had enjoyed their holiday. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 14 The cultural needs of a service user were documented in one of the care records looked at. The service users spoken with said they are supported to maintain relationships with their family and friends. The relationships that are important to the individual were recorded in the care records looked at. Some good interaction was seen between service users and staff during this visit. The need for privacy was observed and respected by the staff. Service users hold a key to their own room and a locked drawer facility is provided. The service users’ rights are respected and recorded. Service users’ responsibility for any housekeeping tasks such as cleaning their own room is recorded in their individual care plan. Mealtimes were relaxed and unhurried. Service users were seen being supported by staff in the appropriate way to prepare food and eat their meal. Service users are supported to be involved in the choice of menu and shopping for food. Specialist diets are provided where needed and healthy eating is encouraged at the home. The service users spoken to during this visit said they enjoyed their meals. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 15 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 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The service users receive personal support in their preferred way. Generally the health care needs of the service users are being met. The home’s medication policy and procedure does not sufficiently protect the service users. EVIDENCE: Service users receive the care and support they need in their preferred way and these preferences are recorded in the care plan. Service users do have some choice of the staff who work with them, and the preferred gender of staff providing personal care was recorded in one of the care records looked at. During this key visit to the home the service users were seen being treated in a dignified and respectful manner. The service users spoken with said they had their own key worker who they liked. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 16 The service users have a health care plan. There was evidence in the care records that the service users are supported to access NHS healthcare facilities. Some service users are unable to access the weighing scales provided at the home. These service users are supported to access sit on weighing scales at another home within the organisation. This is not an ideal situation for the service users affected. Suitable sit on scales should be purchased in order that service users weights can be monitored in the home. A recommendation is made in this report about the matter. The home’s medication system was audited and the medication for two service users was checked. One medication was accurate. One medication could not be fully reconciled with the records kept by the home. This was due to a medication not being carried forward onto the current MAR (Medication Administration Record) sheet. This was discussed with the manager who agreed to take immediate action to rectify the matter. This is the third inspection running where there have been examples of medication procedures not being followed. A letter of concern has been issued to Mencap and requirement made in this report relating to safe medication procedures. In addition, a requirement is also made that all staff who are responsible for medication receive further training and regular medication audits are carried out at the home. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 17 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): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users feel that their views are listened to and acted upon, and they are protected from abuse. EVIDENCE: All the service users who responded to the survey said they knew who to speak with if they were not happy. And all said they knew how to make a complaint. One service user wrote the detailed actions they would take if they had to make a complaint. The home has worked well to ensure the service users are confident to raise a concern or make a complaint. The home has a complaints policy and procedure in place and is in a suitable format for service users. There have been no complaints made to the home in the last twelve months. All the staff working at the home has undertaken protection of vulnerable adults training. The staff working at the home have a good understanding of adult protection and the required actions that must be taken should there be any allegations of abuse. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home is clean and hygienic and the service users live in a homely and generally well maintained environment. EVIDENCE: The service users who responded to the survey said that the home is always fresh and clean. Service users are supported to clean their own room when they are able to do so. The level of support required for the individual to carry out this task is recorded in their plan of care. The home is clean and generally well maintained, and was odour free during this visit. The home has purchased new easy chairs and sofas since the last visit by the Commission for Social Care Inspection. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 19 During a tour of the home the laundry facilities were seen and were clean and well organised. All the staff working at the home has completed infection control training. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 20 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): 32,34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A competent staff team supports service users. The home’s recruitment policy and procedure requires some improvement to ensure it is sufficiently robust to protect the service users. EVIDENCE: The service users that responded to the survey said that the staff always treat them well. During this visit the service users spoken with said that they liked the staff who work at the home. The relatives’ and GPs’ surveys received by the CSCI said that they were satisfied with the overall care provided at the home. The manager confirmed that 46 of the staff have achieved NVQ (National Vocational Qualification) level 2 or above in care. The remainder of the staff are ongoing with this training. All staff has completed LDAF (Learning Disability Award Framework) accredited training. The manager and the organisation have worked well to ensure that Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 21 all staff have completed training in Infection Control, First Aid, Fire, Manual handling and POVA (protection of vulnerable adults). The records for two staff working in the home were audited. One of the records held the required information. The other record examined did not have a full employment history. All staff should have a full employment history and any gaps should be explored. A discussion took place with the manager regarding the safe keeping of satisfactory police checks, Criminal Record Bureau (CRB) checks. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 22 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): 37,39 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users benefit from a home a well run home. The home is run in the best interests of the service users. The health, safety and welfare of the service users, and the staff, is promoted and protected. EVIDENCE: The home’s registered manager is Ms Theresa Kelly. She has commenced the NVQ (National Vocational Qualification) level 4 training. The staff spoken with during this visit said that Ms Kelly continues to be approachable and supportive to both the service users and the staff. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 23 There is a quality monitoring system in place. Service users are supported to hold meetings on a monthly basis. Monthly management review reports are completed and quality audits are completed by the home. The results of consumer surveys are made available in the home. The information received by the CSCI shows that the equipment in the home is serviced regularly. The recommendation made at the last visit to the home regarding the maintaining of hot water temperatures has been addressed. All staff have completed fire training. The fire records were checked and were up to date. Regular fire drills are carried out at the home and the service users are supported to be involved in this practice. Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 3 X Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 25 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 YA20 Regulation 13.2 Requirement The policy and procedure for medication must be followed to protect the service users. The medication records must be kept up to date. All medication carried forward from the previous month must be transferred onto the current MAR sheet. Previous timescale of 16/08/05 and 12/02/06 not met. 2. YA20 13.2 The staff responsible for handling 30/12/06 medication in the home must undertake medication training. In addition to this training the registered person must carry out regular medication audits. Timescale for action 16/11/06 Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 26 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. Refer to Standard YA6 YA19 Good Practice Recommendations Where a care plan is reviewed and there are changes to the care being provided. The changes identified should be reflected in the working care plan. Suitable scales should be purchased to accurately record the weight of service users. This would allow individuals to be weighed at regular intervals in their own home. The employment history of all staff working at the care home should be recorded in the staff files kept 3. YA34 Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Brighouse Area Office St Pauls House 23 Park Square (South) Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 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 Huddersfield Mencap 4 DS0000026344.V311620.R01.S.doc Version 5.2 Page 28 - 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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