Inspection on 24/08/06 for Mencap In Kirklees

This inspection was carried out on 24th August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 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 18/01/06

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 24th August 2006 08:45 Huddersfield Mencap 5 DS0000026345.V301378.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 5 DS0000026345.V301378.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 5 DS0000026345.V301378.R01.S.doc Version 5.2 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.V301378.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th January 2006 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 home’s bedrooms are single, some of which are self contained. The home has adequate communal facilities. The home is surrounded by a grassed area. The registered provider informed the Commission for Social Care Inspection on 29/7/06 that the fees are £414.74. There are additional charges for hairdressing, newspapers and magazines, toiletries, trips and holidays. 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 5 DS0000026345.V301378.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 inspector arrived at the home at 8.45am and left at 3.15pm. During this visit the inspector spoke to some service users, some of the staff and the home’s manager Ms Yvonne O’Toole. 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 eight questionnaires to service users living at Huddersfield Mencap 5. All the questionnaires were completed and returned. There were eight service users living at the home on the day of this visit. Surveys were sent to ten service users’ relatives and three GPs. At the time of writing this report, the inspector had received responses from five relatives and none from 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, copies of the monthly management visit reports produced by the care provider, and a pre-inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance with this inspection. What the service does well: The service users are supported in a warm and caring environment. The service users said that the staff treat them well and they are happy at the home. The service users made positive comments about the staff working in the care home. The inspector observed positive interaction between the service users and the staff team. There is evidence that the service users are involved in the development of their care plans. These plans continue to be person centred and reflect the choices made by the individual in their daily lives. All the service users spoken with during this visit said that they knew who to speak with should they have any concerns or wish to make a complaint. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 6 The home has a friendly atmosphere and all visitors are made to feel welcome. There were positive comments from service users regarding the meals being served in the home. During this visit, the inspector observed service users supported to make choices about menus and some service users being supported to make their own meals. 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 DS0000026345.V301378.R01.S.doc Version 5.2 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.V301378.R01.S.doc Version 5.2 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 service users’ individuals needs and aspirations are assessed prior to admission. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: There have been no recent admissions to the home. The admission process was discussed with the manager who said that potential service users would only be admitted to the home following a full assessment and visits to the home. One respondent from the service user survey states that they were asked if they wanted to move into the care home. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 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): 6,7 and 9. The service users know that their assessed personal needs and goals are recorded in their care plan. The service users are supported to make decisions about their lives. Service users are supported to take risks as part of an independent lifestyle. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The service users spoken with said they were happy living at the home. There were positive comments made by the service users regarding the support they receive from the staff team. The responses from the service user surveys state that service users make choices and decisions each day about what they do. Care records for three service users were audited during this visit to the home. The care records continue to be detailed, person-centred and reflect the individuals’ choices and lifestyle. The service users said they had been involved Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 10 in the formulation and review of their plan of care. The service users spoken with said that they had a key worker. The choices and decisions made by service users are documented in their individual care record. Service users are supported to manage their own finances with support from the staff when required. There were up to date risk assessments detailing the action required to minimize identified risks and hazards to support the service users to take part in an independent lifestyle. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 11 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): 12,13,15,16 and 17. 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 rights of the service users are respected and the individuals’ choice and independence is promoted. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The service users are supported to find jobs and continue employment should they wish to do so. All the service users have care plans that relate to education and employment. One service user said their key worker was supporting them to seek suitable employment. Service users are supported to be part of the local community. During this visit to the home, service users were discussing their planned annual holiday. The Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 12 service users spoken with said they enjoy going out with the staff to the local shops, pub and other places of interest. The service users are supported to maintain links with family and friends, and the contact with family and friends is recorded in their care records. The service users spoken with said that their family and friends are made welcome in the home. The home enjoys a relaxed and homely atmosphere and staff interact well with the service users. The service users were observed being treated in a respectful manner by the staff. The right to privacy is recorded in the individuals’ care records. All the service users are provided with a key to their own room should they wish to use it. The rights of the service users are promoted and recorded. During this visit the inspector noted that service users were handed their mail unopened. The home offers a varied choice of menu and the service users said there is always a variety of food and drink available. During this visit the service users were supported in their choice of meal; some service users made their own meal. The service users said they enjoy the meals provided in the home and that they are encouraged to plan menus and to go shopping for food. The nutritional needs and the support required by the individual are recorded in their plan of care. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 13 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 and 20. The service users receive personal support in their preferred way. Service users’ healthcare needs are being met. The medication policy and procedure sufficiently protects the service users. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The service users spoken with said the staff provide the personal support they require. The support required and other preferences made by service users, such as choice of clothing, choice of staff for assistance with bathing, is recorded in their individual plan of care. Service users do have some choice of the staff who provide support for them, and the preferred gender of staff is recorded in the individual care records kept. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 14 All service users have a health care plan and are supported to access NHS healthcare appointments and facilities. In addition, the service users have their weight monitored on a monthly basis. The home has a medication policy and procedure in place although this is in need of review. The manager said that all the staff who dispense medication have undertaken the relevant training. Three service users’ medications were audited and the medication checked could be reconciled with the records kept. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 15 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): The service users feel that their views are listened to and acted upon, and they are protected from abuse. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The respondents’ survey stated that the service users know who to speak to if they are not happy. There is a complaints policy and procedure clearly displayed in the home and there have been no complaints made to the home during the last twelve months. The service users spoken with said they knew who to speak to should they have any concerns or need to make a complaint. The home has a whistle blowing policy and procedure available and the staff spoken with said they understood this procedure. There are some staff who require the protection of vulnerable adults training and this should be addressed as part of the home’s training programme. The staff spoken with during this visit had a good understanding of adult protection issues and the relevant actions that should be taken following any allegations of abuse. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 16 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 and 30. The home is clean and hygienic and the service users live in a homely, comfortable and generally safe environment. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The service users who responded to the survey said that the home is usually fresh and clean. On the day of this visit, the home was clean and odour free. There have been many improvement works carried out in the home in recent months. Generally the home is safe and comfortable. In the best interests of all the service users living at the home, radiator covers should be fitted to all radiators. The manager said that there are plans to complete the remaining repairs and redecoration during the next few months. The inspector completed a tour of the home and the service users’ rooms looked at had been personalised by the service users. The bathrooms have been replaced and retiled. A toilet to the first floor continues to need a hand washbasin. This should be addressed as part of the Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 17 ongoing improvement works in order to promote safe hygiene in the home and reduce the risk of cross infection. There have been no improvements to the home’s laundry facilities. This area was discussed with the manager. In order to reduce any potential risk to the service users and the staff, this area needs to be risk assessed. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 18 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 and 35 A competent staff team supports the service users. The organisation has taken action to ensure service users are protected by the home’s recruitment policy and procedure. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The respondents to the service user survey said that the staff always treated them well and listened to what they had to say. Those who responded to the relative survey indicated that they were satisfied with the overall care provided in the home. During this visit, all the service users spoken with said that they were happy with the care provided by the staff team. The information received by the Commission for Social Care Inspection states that one member of staff has achieved NVQ level 2, and the manager confirmed that a further three staff are working towards this qualification. Three staff confirmed that they had undertaken induction training provided by the organisation. Three staff have completed LDAF (Learning Disability Award Framework) accredited training. Some staff require further training (see standard 42) and the organisation should develop a staff training and development plan. The inspector found it difficult to trace the training Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 19 completed by the staff. All training should be recorded in the individual staff record. There has been no newly appointed staff working in the home since the last visit by the Commission for Social Care Inspection. However, the organisation has taken action to ensure the staff records looked at were up to date and contained all the required information. A discussion took place with the manager regarding the suitable keeping of staff police checks. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 20 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 and 42. Service users benefit from 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 staff is generally promoted and protected. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Ms Yvonne O’Toole is the registered manager of the home. During this visit the service users made positive comments about the manager. The staff commented that the manager is very supportive. Ms O’Toole will commence NVQ level 4 training September 2006. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 21 The home has a quality monitoring system in place. The service users said that they are supported to air their views and there are regular service users’ meetings. The respondents to the service users’ survey stated that the staff listen and act on what they have to say. The quality assurance report was made available to the inspector and the results of this quality audit were positive. Health and safety procedures in the home protect service users and staff. There is a fire procedure clearly displayed in the home. The fire records kept were checked and were up to date. Fire drills and the testing of the fire safety equipment are completed on a weekly basis. The fire officer has recently visited the home. A sample of health and safety records was checked and was found to be up to date. Information provided to the Commission states that five staff hold a current first aid certificate. Because the policy and procedures and general management of the home is generally effective, the outcome for this group has been judged as good. However, fire training and infection control training is required for two staff and movement and handling training is required for four staff, therefore a requirement has been made. This should be complied with urgently to ensure safe working practices. Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 22 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 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 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 3 x 3 X 3 X X 2 X Huddersfield Mencap 5 DS0000026345.V301378.R01.S.doc Version 5.2 Page 23 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 YA42 Regulation 23 (4) (d) Requirement Timescale for action 24/11/06 2. 3. YA42 YA42 13 (5) 13 (3) The registered person shall after consultation with the fire authority make arrangements for persons working at the care home to receive suitable training in fire prevention. Previous timescale 18/04/06 not met. Staff must receive training in 24/11/06 safe movement and handling of service users Staff must receive training in 24/11/06 infection control 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. Refer to Standard YA23 YA24 YA30 Good Practice Recommendations All staff should undertake adult protection training. A hand washbasin should be fitted to the identified toilet in order to promote good hygiene standards and infection control. An environmental risk assessment should be completed in respect of the laundry area. DS0000026345.V301378.R01.S.doc Version 5.2 Page 24 Huddersfield Mencap 5 4. 5. YA32 YA35 All the home’s staff should complete NVQ training. 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. To ensure safe working practice: It is recommended that all staff should complete annual movement and handling training. To ensure safe working practice: It is recommended that all staff should undertake six monthly updates in fire training. 6. YA42 7. 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