CARE HOME ADULTS 18-65
Leys Road (2/4) 2/4 Leys Road Hemel Hempstead Hertfordshire HP3 9LX Lead Inspector
Alison Jessop Unannounced Inspection 11th October 2005 10:00 Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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 Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Leys Road (2/4) Address 2/4 Leys Road Hemel Hempstead Hertfordshire HP3 9LX 01442 389 214 01442 389 214 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) Hightown Praetorian & Churches Housing Association Mr Ian Searle Care Home 7 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (7), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (7) Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Only Service Users who are independently ambulant may be accommodated. 10th May 2005 Date of last inspection Brief Description of the Service: Leys Road provides accommodation, care and support for seven service users who have a history of mental health issues. The home is arranged on three floors. There is no lift so the home would be unsuitable for anyone with restricted mobility. The service users are currently all able to manage the stairs independently. Accommodation comprises of a quiet room, kitchen, lounge, dining room and toilet on the ground floor. The first floor consists of three bedrooms, shower room, toilet and office. The second floor comprises of four bedrooms, two bathrooms and a toilet. Leys Road is situated close to the town centre of Hemel Hempstead. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This positive unannounced inspection was carried out by two Regulation Inspectors over half a day. This was the second visit to the home in the inspection year. Feedback from service users and staff was very positive, most service users and staff have worked at the home for a number of years and therefore the home offers a familiar environment. Although most of the time was spent talking to the service users and staff, time was also spent talking to the manager and inspecting care plans and other required documentation. No immediate requirements were made. What the service does well:
On entry to Leys Road the home offers a comfortable and homely environment. It is attractively decorated and is very clean throughout. Staff working at the home take pride in its appearance. The domestic stated ‘I treat it as I would my own home. I really enjoy working here.’ Service users were very positive about all aspects of the home and their care. They all said that they liked living at Leys Road and felt supported by the staff team. One service user said ‘I like living here, the staff are nice, we sometimes go to the shops together or I can go by myself.’ Care plans and risk assessments are available and are reviewed regularly. These generally contain comprehensive information about the service user and appear to be used as working documents. Service users had been on holiday recently and feedback about this was very positive. One service user said ‘it’s the best holiday I have ever been on.’ A number of social events had taken place with more planned for the future. No complaints have been received since the last inspection report. The staff in the home following an incident involving two service users had instigated the Protection of Vulnerable Adults Procedure. This was dealt with really well by the team who promptly ensured that all service users were protected from harm. One compliment was received from the family of the service user who had perpetrated the abuse, who said that the staff had done a good job with supporting their son. The garden contains a vegetable patch where service users with the support of staff grow fruit and vegetables. A good crop had been produced this year, which service users enjoyed picking and eating. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 Page 6 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. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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 Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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): None of these standards were inspected on this occasion. EVIDENCE: Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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 Service users are encouraged to live an independent lifestyle, most service users go out without the support of staff and any risks identified are recorded in the service users individual risk assessment, minimising or eliminating the risks as far as possible. EVIDENCE: One service user had expressed an interest to get a bike. He had owned a bike many years previously and wanted to pursue this interest again. The manager stated that he talked to the service user to discuss the risks of riding on roads now, as the roads are much busier than they were years ago. The manager stated that they would have assisted the service user to get a bike but that a lot of work would have to be done to ensure that he is safe riding it. The service user changed his mind and decided to get an organ instead. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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): 11,12,13 & 14 The home promotes integration and choice; service users are actively encouraged to participate in the local community ensuring that they maintain an independent lifestyle. EVIDENCE: Although all of the service users were at home for part or all of the inspection some go out on a daily basis. One service user returned from his voluntary employment where he works on a gardening project. Another went out to the doctor’s surgery with a member of staff. One service user who is older and has become quite frail spends more time in her bedroom. She was observed sitting in the dining room reading the newspaper however staff reported that she does spend more time in her bedroom. Staff were confident that they could continue to meet her needs. Several service users had been on holiday to Wales earlier in the year and were all very positive about this. One service user said ‘it’s the best holiday I have ever been on.’
Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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 & 21 Staff encourage service users to attend to their own needs ensuring that they maintain their independence. One service user who requires assistance with personal care appeared happy with the arrangements and had been given a choice about her care plan. EVIDENCE: One older service user requires assistance with washing and had been offered assistance with bathing however this had been refused. Her care plan clearly stated how the service users needs were to be met and risk assessments were available. Each service user has been asked about their wishes in the event of their death. The service user had commented that she did not wish to answer this as she felt it is morbid, however the staff had recorded her response and had signed and dated this statement. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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 the following standard(s): 22&23 Original documentation and identification of service users is stored more securely, protecting them from financial abuse. EVIDENCE: The complaints procedure, which is given to service users when they move into the home, has been reviewed and reflects the Commission for Social Care Inspection. No complaints have been received since the last inspection. A serious incident had occurred at the home recently where by one service user assaulted another service user. Staff at the home took immediate action. The POVA procedure was instigated and an emergency strategy meeting held. The home took immediate action to ensure that the safety of all service users and staff was protected. The perpetrator has since been evicted from the home and on-going support is being provided to the victim. Staff have also offered specialist input from the Victim Support Service and Adult Care Services. Staff spoken to confirmed that they felt supported and protected during this difficult time. The situation was handled extremely well. Staff records in relation to recruitment were observed and appeared to be satisfactory. A copy of the Hertfordshire Protection of Vulnerable Adults was available in the staff office/sleep in room. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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 the following standard(s): 24 & 30 The home offers a pleasant and comfortable environment to its service users. All areas of the home observed were very clean and tidy and the new kitchen appears to have boosted a positive perception within the home encouraging service users to keep this clean and tidy. EVIDENCE: The new beech kitchen offers a light, bright and clean area for service users and staff to prepare food and drinks. Service users and staff were very positive about this. One service user said ‘we were asked what colour we would like the décor and flooring.’ One service users bedroom is quite cluttered, a requirement was made at the previous inspection for this to be tidied and made safe, as it was a fire hazard. Some plastic storage boxes had been provided however further work was recommended. The window restrictors in this service users bedroom had broken off and a requirement has been made for these to be replaced. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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 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): 34 & 35 Although staff had completed mandatory training recently, they could be given the opportunity to attend specialist training, particularly for new staff in relation to Mental Health. This could further enhance the service already being provided. EVIDENCE: Documentation in relation to recruitment was adequate however it was recommended that any gaps in employment are investigated and recorded. Staff records observed included lists of training undertaken. Recently staff had attended Fire Safety, Manual Handling and Food Hygiene. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 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 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): 39 & 42 Problems with the hot water temperatures remain and were identified at previous inspections. Risk assessments have been completed and notices have been left on bathroom doors thus reducing the risk to service users. EVIDENCE: This years Quality Assurance Survey has not yet been conducted and is organised centrally by High Town Praetorian. The manager stated that residents have decided that they would like to have meetings every other month and minutes of the last meeting were observed. The home also has a grumbles book in the lounge however no entries had been made since the last inspection. Water temperatures were being regularly tested and recorded however the bathroom water temperatures remain high. The manager stated that this has been looked at by maintenance and that there is a way of turning the temperatures down which he confirmed he would do immediately. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 Page 16 Fire Safety equipment is over due to be tested. The manager stated that a new company have been commissioned to carry this out however they have not been to Leys Road. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 Page 17 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 X X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 2 X X X X X 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Leys Road (2/4) Score 3 3 X 3 Standard No 37 38 39 40 41 42 43 Score X X 2 X X 2 X DS0000019447.V256938.R01.S.doc Version 5.0 Page 18 No 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 13 (4) (c) Timescale for action Window restrictors must be fitted 31/10/05 to all first and second floor windows. A risk assessment must be carried out and a copy submitted to CSCI. Fire Safety equipment must be 31/10/05 tested in accordance with the Fire Precautions Act 1971 and the Fire Precautions (Workplace) Regulations 1977. Requirement 2 YA42 23 (4)(c) (iv) &(v) 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 YA34 YA35 YA39 Good Practice Recommendations Any gaps in employment should be questioned and recorded when recruiting new staff. More specialist staff training could further enhance and develop skills and knowledge, particularly specialist mental health training to new staff. Once completed a copy of the annual Quality Assurance report should be sent to CSCI. Leys Road (2/4) DS0000019447.V256938.R01.S.doc Version 5.0 Page 19 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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