Inspection on 24/08/05 for Mencap In Kirklees

This inspection was carried out on 24th August 2005.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

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 18/01/06

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 HD3 3TP Lead Inspector Bronwynn Bennett Unannounced 24 August 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. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Huddersfield Mencap 5 Address 100 Pennine Crescent Salendine Nook Huddersfield HD3 3TP 01484 348961 01484 348961 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) Huddersfield Mencap Mrs Yvonne Margaret OToole Care Home 8 Category(ies) of 8 places for people aged 18-65, with a learning registration, with number disability of places Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 20 January 2005 Brief Description of the Service: 100 Pennine Crescent is a care home providing personal care and accommodation for eight youger adults with learning disabilitites. 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 aminities. 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 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection lasting for a period of approximately four hours. The service users, two relatives and the staff on duty were spoken with. The inspector also looked at written records. 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 report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 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 Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 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) 2. A record of the pre-admission assessment should be kept in the residents care records. EVIDENCE: There was no written record of a pre-admission assessment being undertaken for one resident admitted into the home. A discussion took place with the manager about this. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 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) 6,7,9. The staff are working well in meeting the needs of the service users. The service users are supported to make decisions about their daily lives. The care plan should be drawn up and reviewed with the involvement of the service user, family and friends as appropriate, and any relevant agencies. EVIDENCE: The service users spoken with said that they are happy with the staff team and that the staff are supportive. Two relatives spoke highly of the staff at the home and said that they were supportive. The care records were looked at for three service users. Two care records were good and gave detailed information. It was evident that two service users have been consulted in the development and the review of their plan of care. One service user who has recently been admitted into the home did not have an up to date plan of care or risk assessments in place. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 9 Three of the daily records looked at gave insufficient detail and did not reflect the individual plan of care. This was discussed with the manager and needs to be addressed. There was observed and written evidence in two care records that the staff support the service users to make decisions in their daily lives. Some of the service users attend self- advocacy groups. Two care records had up to date risk assessments in place that gave detailed information of how to minimize risks and hazards. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 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 standard(s) 12,13,15,17. The service users are supported by the staff to find jobs and take part in activities in the community. The service users are supported to maintain relationships with family and friends. EVIDENCE: The staff support the service users to find appropriate jobs, education and training. The service users are part of the local community and frequently go out to the local shops, pubs and clubs. Some service users were looking forward to going on a planned holiday with friends. The service users spoken with said that they are supported with family relationships. Two relatives said that the staff make them feel welcome when visiting the home. There was evidence in the service user records that the residents are supported to maintain relationships. The home has a menu in place. The service users are consulted daily about their choice of meals and a record is kept of the food served for the main meal. The service users spoken with said that the staff offer a choice of foods and support to eat a healthy diet. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 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) 19,20. Some of the resident’s health care needs are met, but some residents are at risk of their nutritional health care needs not been met. The home’s policy and procedure for medication must be followed and greater care needs to be taken with the safe handling of medication. EVIDENCE: There are assessments in place for the service users health care needs. Specialist medical care is provided for those who require it and the staff are supportive in working through medical changes for the service users. There were no nutritional assessments in place for the service users, and no evidence in the care records of the action taken should there be a significant weight loss or weight gain. The frequency for weighing the service users was not consistent with the individual plan of care and this was discussed with the manager. The home has a policy and procedure in place for medication. The medication records were looked at for three residents. The medication for one service user had not been given at the time prescribed by general practitioner, and this action had not been recorded in the MAR records. This is not acceptable and was discussed with the manager. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 12 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. The residents are able to raise any concerns or make a complaint. The staff have a good understanding of adult protection. EVIDENCE: The home has a complaints procedure displayed that is in need of updating to give the information of how to contact the Commission for Social Care Inspection. There are meetings held on a regular basis to allow the service users to raise concerns and air their views. The service users spoken to said that they would feel comfortable to raise a concern or make a complaint. The relatives spoken with said that their views are always listened to and acted on. The staff spoken to had a good understanding of the appropriate action to take should there be any allegation of abuse. The manager advised that some of the staff are awaiting training for the protection of vulnerable adults. The home has a whistle blowing policy that is in need of updating to include the details of how to contact the Commission for Social Care Inspection. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 13 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) 24,30. The home was generally clean and tidy. The organisation should give consideration to a regular handyperson service. The lack of suitable hand washing facilities poses a health and safety risk. EVIDENCE: The service users live in a clean and homely environment. There is a plan for refurbishment in the home and these works are planned for completion later in the year. It is expected that the home will be redecorated following this work. The home does not have the input of a regular handyperson and this was discussed with the manager. The laundry facilities were clean and well organised, but are in need of repair and redecorating. The washing machine has a sluicing facility and is able to meet disinfection standards. There is a procedure in place for clinical waste and infection control. The home has a contract for water services and fittings. There were no hand washing facilities available in the laundry areas or the communal toilet facilities and this was discussed with the manager. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 14 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) EVIDENCE: Not assessed during this inspection. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 15 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) 37,42. The manager should complete the recommended qualification. The manager should take action to ensure the health and safety of the service users. EVIDENCE: The manager has not yet completed the NVQ 4 in management. There are policies and procedures in the home for health and safety and fire safety. It was evident that there have been two occasions when the testing of the fire alarm system and emergency lighting has not been completed and this was discussed with the manager. The home has a contract for water testing and the testing for gas safety and the electrical equipment has recently been completed. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 2 x x x Standard No 22 23 ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 2 x 1 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 1 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Huddersfield Mencap 5 Score x 2 1 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 17 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 6 Regulation 15 Requirement The registered person should prepare a written service user plan. The care plan should be drawn up and reviewed with the involvement of the service user, family and friends as appropriate, and any relevant agencies Risk should be assessed and discussed with the service user. The agreed risk management should be recorded and reviewed in the individuals care plan. The policy and procedure for medication must be followed to protect the residents. There should be suitable arrangements to prevent the spread of infection in the care home. A hand wash dispenser and paper towels should be made available in the laundry and toilet facilities. Timescale for action 6.10.05 2. 9 13 6.10.05 3. 4. 20 30 13.2 13.3 24.8.05 6.10.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 18 No. 1. 2. 3. 4. Refer to Standard 2 6 7 19 Good Practice Recommendations The pre-admission assessment should be kept in the service users care records. The daily records should reflect the delivery of the individual residents plan of care. The decisions made by the service users should be documented in the care plan. Nutritional risk assessments should be kept for all service users. The service users should be weighed monthly to monitor any significant weight gain or weight loss. The complaints procedure should be updated to include the information of how to contact the Commission for Social Care Inspection. The whistle blowing policy should include the information of how to contact the Commission for Social Care Inspection. The home should consider appointing a handyperson to carry out repairs in the home. The manager should obtain the NVQ level 4 qualification in management. The manager should ensure that the fire alarm system and the emergency lighting is tested on a weekly basis. 5. 6. 7. 8. 9. 22 23 24 37 42 Huddersfield Mencap 5 20050823 Mencap 5 UI x00023 J51 v245819 s26345.doc Version 1.40 Page 19 Commission for Social Care Inspection 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. 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