Inspection on 18/01/06 for Mencap In Kirklees

This inspection was carried out on 18th 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mencap In Kirklees 05/08/09

Mencap In Kirklees 08/08/07

Mencap In Kirklees 24/08/06

Mencap In Kirklees 24/08/05

Mencap In Kirklees 20/01/05

Mencap In Kirklees 19/10/04

Mencap In Kirklees 17/02/04

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 5 100 Pennine Crescent Salendine Nook Huddersfield West Yorkshire HD3 3TP Lead Inspector Bronwynn Bennett Unannounced Inspection 18th January 2006 10:30 Huddersfield Mencap 5 DS0000026345.V251257.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 5 DS0000026345.V251257.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 5 DS0000026345.V251257.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Huddersfield Mencap 5 Address 100 Pennine Crescent Salendine Nook Huddersfield West Yorkshire HD3 3TP 01484 348961 01484 340822 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 Yvonne Margaret O`Toole Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Huddersfield Mencap 5 DS0000026345.V251257.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th August 2005 Brief Description of the Service: 100 Pennine Crescent is a care home providing personal care and accommodation for eight younger adults with learning disabilities. It is owned by Huddersfield Mencap, a charity working locally in the field of learning disabilities. The home is situated in Salendine Nook near Huddersfield with good transport facilities and some local amenities. It is a two storey detached building with an attached bungalow adjacent to some similar properties provided with warden services. All the homes bedrooms are single, some of which are self contained. The home has adequate communal facilities. The home is surrounded by a grassed area. Huddersfield Mencap 5 DS0000026345.V251257.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 18th January 2006. The inspection was conducted over a four and a half-hour period and included the examination of files kept by the home. Some of the service users 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 24th August 2005. What the service does well: What has improved since the last inspection? What they could do better: Greater care needs to be taken in the monitoring of the nutritional health care needs of the service users. The organisation should develop a staff training and development programme to ensure that staff are appropriately trained to meet the needs of the service users. The recruitment process is not sufficiently robust to protect the service users. Please contact the provider for advice of actions taken in response to this Huddersfield Mencap 5 DS0000026345.V251257.R01.S.doc Version 5.1 Page 6 inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Huddersfield Mencap 5 DS0000026345.V251257.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 5 DS0000026345.V251257.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. There is some evidence to indicate that the potential needs of the service users are assessed prior to admission into the home. EVIDENCE: A recommendation was made during the last inspection that pre admission assessments should be kept in service users’ files. The previous care file identified held a social workers community care assessment, however the organisation should develop a policy and procedure for admission into the care home. Huddersfield Mencap 5 DS0000026345.V251257.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): 6,9. The service users needs and personal goals are evidenced in the individual’s plan of care. The service users are supported to make decisions in their daily lives. EVIDENCE: The service users spoken with said they were satisfied with the care and support that they receive from the staff and advised the inspector that they are consulted about their plan of care. The care records were looked at for two service users. Generally the standards of these records were good and gave detailed information. There were relevant risk assessments in place that were detailed and up to date. It was evident that the service users had been involved in the development and review of their plan of care. The manager has worked hard to improve the service users daily records. The inspector noted that these records gave more detail and reflected the individual’s plan of care. Huddersfield Mencap 5 DS0000026345.V251257.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 service users rights are promoted and respected. EVIDENCE: The service users spoken with said that they were satisfied with the care and support that they receive from the staff. One service user commented that the staff are “Great” and during this inspection the inspector observed good relationships between the service users and the staff. Service users are offered keys to their own rooms and where a service user has chosen to complete domestic tasks this was documented in their plan of care. Huddersfield Mencap 5 DS0000026345.V251257.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): 18,19,20. The service users receive the care and support they require in the preferred way. There is a potential risk of some of the service users health care needs not been met. Generally the policy and procedure for medication protects the service users. EVIDENCE: The service users said that they are able to choose their preferred activities, wake up and retiring times, choice of food and choose their own clothing. The guidance and support that a service user may require was seen documented in their plan of care. The nutritional risk assessments looked at were up to date. A discussion took place with the manager about the completion of nutritional assessments and the actions required when a service user has had a significant weight gain or weight loss. The oral hygiene needs of the service users’ were not clear in the care records examined and this was discussed with the manager. The medication records were examined for two service users and the medication could be reconciled with the records kept. Huddersfield Mencap 5 DS0000026345.V251257.R01.S.doc Version 5.1 Page 12 Huddersfield Mencap 5 DS0000026345.V251257.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 is displayed and the whistle blowing policy has been updated to include the information of how to contact the Commission for Social Care Inspection. Huddersfield Mencap 5 DS0000026345.V251257.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): EVIDENCE: These standards were not assessed during this inspection, however the home was generally clean and tidy on the day of this inspection. There has been some refurbishment in the home and further works are planned for the coming months. The requirement from the last inspection regarding hand washing facilities has now been addressed. Huddersfield Mencap 5 DS0000026345.V251257.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. Generally a competent staff team supports the service users, however staff training is in need of some development in order to ensure that the staff are sufficiently trained and to do their jobs. The recruitment practices are not sufficiently robust to protect the service users. EVIDENCE: There are currently three staff working towards NVQ level 2 certificates. The manager said that she supports the staff to develop working skills and knowledge that is relevant to their working practice. Four of the staff has completed LDAF (Learning Disability Award Framework) accredited training. There was evidence of one member of staff undertaking induction and foundation training. A staff training and development plan was not made available during this inspection. Three staff files were audited. There were no original police checks kept in staff files and one police check had been transferred from another organisation. There were gaps in the employment histories for one member of staff and one of the records did not have suitable references. Improvements need to be made regarding the information held in staff records relating to the relevance of references and this was discussed with the manager. The current recruitment practice is not acceptable and needs to be addressed. Huddersfield Mencap 5 DS0000026345.V251257.R01.S.doc Version 5.1 Page 16 Huddersfield Mencap 5 DS0000026345.V251257.R01.S.doc Version 5.1 Page 17 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 manager is competent and fit to run the care home. There is a quality monitoring system in place that seeks the views of the service users. The health and safety of the service users is not sufficiently promoted and protected. EVIDENCE: The manager Mrs Yvonne O’Toole is registered with the Commission for Social Care Inspection. 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 service users, staff and other stakeholders Huddersfield Mencap 5 DS0000026345.V251257.R01.S.doc Version 5.1 Page 18 through questionnaires and consultation. The manager said that feedback is actively sought from the service users and that there are regular audits conducted in the home. There were gaps in the records for the weekly testing of the homes fire alarm system. Action must be taken in this matter in order to protect the service users. The emergency lighting checks must be undertaken on a weekly basis with daily visual checks being carried out. There are some fire safety works outstanding at the home. It is expected that this work will be completed by February 2006. The staff and the service users take part in regular fire drills. There are three staff in need of fire safety training, this must be addressed in order to protect the service users The staff are in need of movement and handling training. This area of training needs to be addressed in order to protect the staff and the service users. Huddersfield Mencap 5 DS0000026345.V251257.R01.S.doc Version 5.1 Page 19 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 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 2 33 X 34 1 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 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 3 X 2 X 3 X X 1 X Huddersfield Mencap 5 DS0000026345.V251257.R01.S.doc Version 5.1 Page 20 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 service users. Action must be taken when a service users has a significant weight gain or weight loss. (Regs 19 (1) a, b, (I) para 1 – 9 of sch 2,c.) The registered person shall not employ a person to work at the care home unless, the person is fit to work in the care home and, they have obtained in respect of that person the information as specified in the requirements opposite. The registered person shall after consultation with the fire authority make adequate arrangements for reviewing fire precautions, and testing fire equipment at suitable intervals. The registered person shall after consultation with the fire authority take adequate precautions against the risk of fire, including the provision of DS0000026345.V251257.R01.S.doc Timescale for action 18/02/06 2. YA34 19 (1) a, b, (I) 18/02/06 3. YA42 23 (4) (c) (v) 18/02/06 4. YA42 23 (4) (a) 18/03/06 Huddersfield Mencap 5 Version 5.1 Page 21 5. YA42 23 (4) (d) suitable fire equipment. The outstanding fire works must be completed. The registered person shall after 18/04/06 consultation with the fire authority make arrangements for persons working at the care home to receive suitable training in fire prevention. 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. Refer to Standard YA2 YA19 YA32 YA34 Good Practice Recommendations The organisation should develop a policy and procedure for the planned admission of service users into the care home. The oral hygiene needs of the service users should be recorded in the individual’s care records kept. All the homes staff should undertake NVQ training. The registered person should seek to obtain references that are appropriate to the work in the care home, and at least one reference should be from the individual’s most recent employer. The organisation should develop a staff training and development programme to ensure the staff are appropriately trained to meet the needs of the service users. The manager should obtain the NVQ level 4 qualification in management. Staff should complete annual movement and handling training. 5. YA35 6. 7. YA37 YA42 Huddersfield Mencap 5 DS0000026345.V251257.R01.S.doc Version 5.1 Page 22 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 5 DS0000026345.V251257.R01.S.doc Version 5.1 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. 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