Inspection on 05/08/09 for Mencap In Kirklees

This inspection was carried out on 5th August 2009.

CQC found this care home to be providing an Adequate service.

The inspector found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mencap In Kirklees 08/08/07

Mencap In Kirklees 24/08/06

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 16/02/2010.

Key inspection report CARE HOME ADULTS 18-65 Huddersfield Mencap 5 100 Pennine Crescent Salendine Nook Huddersfield West Yorkshire HD3 3TP Lead Inspector Alison McCabe Key Unannounced Inspection 5th August 2009 09:50 Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 1 This report is a review of the quality of outcomes that people experience in this care home. We believe high quality care should: • • • • • Be safe Have the right outcomes, including clinical outcomes Be a good experience for the people that use it Help prevent illness, and promote healthy, independent living Be available to those who need it when they need it. We review the quality of the service against outcomes from the National Minimum Standards (NMS). Those standards are written by the Department of Health for each type of care service. Copies of the National Minimum Standards – Care home adults 18-65 can be found at www.dh.gov.uk or bought from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering from the Stationery Office is also available: www.tso.co.uk/bookshop. The mission of the Care Quality Commission is to make care better for people by: • Regulating health and adult social care services to ensure quality and safety standards, drive improvement and stamp out bad practice • Protecting the rights of people who use services, particularly the most vulnerable and those detained under the Mental Health Act 1983 • Providing accessible, trustworthy information on the quality of care and services so people can make better decisions about their care and so that commissioners and providers of services can improve services. • Providing independent public accountability on how commissioners and providers of services are improving the quality of care and providing value for money. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 2 Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report Care Quality Commission General Public 0870 240 7535 (telephone order line) Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. www.cqc.org.uk Internet address Huddersfield Mencap 5 DS0000026345.V376938.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 linda-reilly@huddersfield-mencap.org.uk Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Huddersfield Mencap Manager post vacant Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th August 2007 Brief Description of the Service: Huddersfield Mencap (5) is a care home providing personal care and accommodation for eight younger adults with learning disabilities. It is run 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 Care Quality Commission on 6th August 2009 that the fees for each person living at the home are £445.75 per week. Information about the home and the services provided are available from the home in the Statement of Purpose and the Service User Guide. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is one star. This means the people who use this service experience adequate quality outcomes. This report refers to an inspection, which included an unannounced visit by one inspector on the 29th July 2009, commencing at 10.15 am, and the length of the inspection was eight hours. There were eight people living at the home on the day of the visit. Most people were out during the inspection visit; therefore limited feedback from people living at the home is available. As part of the inspection in order to provide information to help us form judgments about the quality of the service, the manager was asked to complete an annual quality assessment (AQAA) document. To enable people who use the service to comment on the care it provides, we sent surveys to eight people living at the home, seven of which were returned (unfortunately the inspector had not received these at the time of writing the report), ten to staff, four were returned, and three to other professionals involved with people living at the home, two of which were returned. We focused on the key standards and what the outcomes are for people living in the home, as well as matters that were raised at the last inspection. We have reviewed our practice when making requirements, to improve national consistency. Some requirements from previous inspection reports may have been deleted or carried forward into this report as recommendations but only when it is considered that people who use services are not being put at significant risk of harm. In future, if a requirement is repeated, it is likely that enforcement action will be taken. What the service does well: People are assessed before they move into the home to ensure that their needs can be met. People are involved in planning their care, and important people in their lives are also consulted. There are lots of opportunities for people to do activities they enjoy and have chosen to do. Staff are good at helping people to keep in touch with their family and friends. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 6 Staff provide excellent support so that people have a healthy and balanced diet. Good support is provided so people can make choices about their lives; People’s views are listened to. People are supported to keep healthy and attend health care appointments when necessary. People know how to make a complaint. The home is clean and comfortable and people like living there. The manager and staff get on well with the people who live at the home. What has improved since the last inspection? What they could do better: Care plans that are no longer relevant need to be archived so that staff are sure they are meeting individual’s current needs. This matter was discussed with the manager at the time of the visit and she gave assurance that it would be dealt with quickly. A requirement or recommendation has therefore not been made in relation to this. So that individual’s health needs can be met, advice given by the community nurse should be followed. The home needs to make sure that they always protect the health, safety and welfare of the people living at the home. The manager and staff must make sure that they identify possible hazards to people and take the appropriate action to remove the hazards. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 7 The home must make sure that they notify the appropriate people if incidents occur that affect the safety and welfare of people living at the home. If you want to know what action the person responsible for this care home is taking following this report, you can contact them using the details on page 4. The report of this inspection is available from our website www.cqc.org.uk. You can get printed copies from enquiries@cqc.org.uk or by telephoning our order line – 0870 240 7535. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 8 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.V376938.R01.S.doc Version 5.2 Page 9 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. People are assessed prior to them moving into the home to ensure that their needs can be met. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There have been no admissions to the home since the last inspection visit. The annual quality assessment document (AQAA) completed by the home manager, states that a needs assessment is completed by the home prior to an individual being admitted. An opportunity to visit the home, with an overnight stay is offered and a six month trial is then started. Records for three people were looked at and each had an individual assessment, including a Care Management Assessment. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 10 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. People are involved in the care planning process, are supported to take reasonable risks as part of an independent lifestyle and make choices about their lives. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Three care plans were seen, and each had detailed information about how individual’s needs should be met. There was evidence in the records to show that the care plan had been agreed with the individual and they had signed to this effect. It was found in two of the files that elements of the care plan were no longer relevant, and were not being implemented. The manager was advised that it should be clear within each person’s records which care plans are current. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 11 There was evidence that the care plans are reviewed by the keyworker every three months; care plans that are no longer relevant and being implemented should be identified during this process. Six monthly review meetings take place and people are encouraged to invite family and care professionals involved with them. Minutes of these meetings were in the records. Clear behaviour management plans were in place in two of the files, however the records did not demonstrate that these are always followed consistently. This was discussed with the manager at the time. She reported that in both cases, the individual’s behaviour had improved significantly and that staff rarely had to implement the plans. She was advised to update the records to reflect this. Individuals are supported to make decisions about their lives. For example, how to spend their time, what to spend their money on, what to eat etc. Examples of this were seen during the visit where people decided what to have for breakfast and whether or not to go out for the day. The records provided evidence that staff discuss people’s goals and aspirations in one-to one time spent between keyworkers and individuals. Each person has a ‘wish list’ in their file that they have discussed with their keyworker. The keyworker is then responsible for providing support to achieve what is on the list. Detailed risk assessments had been completed for a range of identified risks relating to individuals, and these are regularly reviewed. These provided evidence that people are supported to take reasonable risks as part of an independent lifestyle. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): This is what people staying in this care home experience: People using the service experience good quality outcomes in this area. People living at the home lead active and fulfilling lifestyle, are provided with support to maintain relationships with family and friends and have a healthy and balanced diet. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: People are involved in a range of educational, recreational and employment activities. At the time of the inspection visit, day services that are usually attended were closed for the week, therefore seven people were at home. Staff discussed with people what they would like to do, and most people went out for a pub lunch. One person went to the gym, and another was at a day centre. A record of what activities people have participated in is kept, and it was apparent that a wide range of valued and age appropriate activities are available. Examples include, bowling, cinema, pub, attending slimming club, Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 13 and going to the gym. The AQAA said that everybody living at the home has been supported to obtain a ‘Kirklees Passport to Leisure’, so that a range of leisure activities can be accessed. The manager said that everybody had recently been on holiday to centre parks and had thoroughly enjoyed themselves. One person said that he had enjoyed this, and wanted to abroad next year. Resident meeting minutes are kept and discussions had taken place with everybody about where they would like to go on holiday. Everybody who lives at the home has been involved in a gardening scheme. Vegetables are being grown, and people are supported to harvest and cook them. One person said they really enjoy doing the gardening. Since the visit, the manager has reported that Kirklees Housing, who own the property, have agreed to provide a larger vegetable area with raised beds and Polly tunnel. Contact with family and friends is encouraged and supported. One person received a visitor from their family during the visit, and the records confirmed that people regularly receive and visit family and friends. People have their rights respected. Everybody is offered a key to their bedroom, although the manager said that nobody wants this facility and chooses not to lock their rooms; all keys are available if people change their minds. One person received a letter, and it was observed that it was given to them unopened, and a member of staff then gave support to read the letter. People chose when to get up, have their breakfast, and whether to be alone or spend time in communal areas of the home. Staff were observed to interact with people living at the home and include them in their conversations. The home has worked hard to ensure that people have a healthy and balanced diet. One person has been supported to attend a local slimming club, and has lost significant amounts of weight which has led to them winning an award. Staff are good at helping this person to maintain the weight loss and plan healthy meals. A selection of fresh fruit was available for people to have as snacks, and staff said that they almost always cook meals from scratch using fresh ingredients. One person said that the staff cook the meals, and staff explained that they tend to prepare and cook the evening meals, and support people to make their own breakfast and lunch. Two people live in a semi-independent bungalow attached to the home. This has its own kitchen with cooking facilities. Staff said that one day a week they go into the bungalow to support the people living there to prepare their own meals; the rest of the time, they collect their meals from the main house and take them through to the bungalow. It was explained that the time staff have to support individuals with this is limited. A weekly menu is displayed in the kitchen, and shows that a balanced and varied diet is on offer. Two people spoken to said that they like the meals provided. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 14 Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. People’s health and personal care needs are generally well met. The home deals with people’s medication well. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Care plans give details about how people prefer to be supported with their personal care. Staff were observed to offer discreet and sensitive support. People living at the home are given a choice of who their keyworker is, and there was evidence in the records of some changes that have been made as a result of individual requests. Three files were looked at and each contained a clear health action plan, and evidence that regular health checks are conducted. Good advice and support is given regarding nutrition. Changes in people’s health were recorded and healthcare professionals are consulted about people’s care. It was noted that specific advice given by a healthcare professional to arrange for an individual Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 16 to be prescribed pain relief to be offered as and when needed had not been followed. The manager said that this had not been done, but if it was required, the GP would be contacted and asked to prescribe this. It is recommended that this advice be followed to ensure the individual’s health needs can always met without there being an unnecessary delay. Feedback from two visiting professionals was generally positive. Comments included, “efficient and caring service”, “Liaise with community health and social care teams more. Share concerns before becoming a crisis”. The home uses a monitored dose system for medication. All records and medicines checked were correct. Medication is stored securely and is well organised. A list of staff authorised to administer medication was in the records, including a sample of their signatures. The manager said that all staff receive medication training provided by Boots the chemist. Evidence of this was seen in staff training files. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. People are confident that they will be listened to and any concerns will be dealt with appropriately. The home has a robust procedure for responding to suspicion or evidence of abuse, however it is not always implemented which places people at risk. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A complaints procedure in an easy read format is in each person’s file. One person said that they knew how to complain and who to speak to if they were not happy. Resident meeting minutes showed that everybody had been reminded of the complaints procedure recently. The AQAA states that no complaints have been received in the last twelve months and the manager confirmed this. All staff who completed a survey said that they knew what to do if they had concerns about the home. Procedures are in place about how to safeguard people from abuse and staff have received training in this. Resident meeting minutes showed that this had been discussed with people living at the home and that an abuse awareness video had been shown to people. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 18 In the last twelve months, two referrals have been made to external agencies under safeguarding procedures. However, it was found in daily records that a number of incidents that should have been reported under these procedures had not been. These mostly included incidents of people living at the home being physically assaulted by each other. The home had also failed to notify the Commission. Links with external agencies are adequate but there is a lack of understanding of safeguarding procedures. This leads to inconsistent practice within the home. This was discussed with the manager at the time, and she was reminded of her responsibilities in this area. A requirement has been made in respect of keeping people safe. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 19 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. People live in a home that is usually clean, hygienic and well maintained. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A tour of all the communal areas of the home was conducted at the time of the visit. Only one bedroom was seen, as the other seven people were out and therefore unable to give permission for their rooms to be entered. This bedroom had been personalised by the individual, and they said that they liked their room. The home was reasonably clean, was well furnished and homely. The manager explained that the standard of cleanliness was usually higher but that due to people’s day services being closed for the week, staff had had less time to spend on cleaning than usual. One person said that he was responsible for cleaning his own room with help from staff. The AQAA states that people are supported with household chores. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 20 It was recommended at the last inspection visit that a wash hand basin be fitted in the first floor toilet to promote good standards of hygiene. The manager explained that this had not been done as it was felt that there was insufficient space for even a very small basin to be fitted. Since the visit, the manager has informed the Commission that she will be discussing possible options with her manager regarding this. There are three bathrooms, each with a toilet and one separate toilet for eight people living at the home. New furniture for the lounge has been purchased since the last visit. No office space is available in the home, therefore all files and records are stored in the lounge and kitchen areas. Attractive furniture that is unobtrusive has been purchased, and the manager reported that this has improved the look of the lounge. Three staff commented in surveys that a separate office would improve the service. There is currently no option for this facility due to a lack of space. The manager said that private meetings and discussions are held in the bungalow which is attached to the main house, if the people that live there are out, or agree to come into the main part of the house. The manager reported in the AQAA that new carpets and furniture have been purchased for people’s bedrooms. Unfortunately, only one person was in during the visit, so the remaining rooms were not seen, and people were not available to give their opinions of their rooms. Staff have worked hard with people at the home to develop the vegetable patch in the garden. This has been a great success and people are reported to enjoy this activity. Further development of the vegetable area has been agreed, and the manager said they were hoping to involve some of the local residents in the gardening scheme. One person living at the home said he had enjoyed eating the vegetables from the garden and showed the inspector a range of new vegetables waiting to be planted. Maintenance records were seen, and it was noted that the shower in the bungalow bathroom had been out of use since 30th July. Since the visit, the manager has confirmed that the shower has been replaced and is now working. Concerns about actions taken when the shower stopped working are discussed in more detail under ‘conduct and management of the home’. The handle on the door to the oven in the bungalow is broken and needs to be repaired. There was no record of this in the maintenance book. There is no laundry room at the home; facilities are located in a corridor that joins the main house to the bungalow. Three staff members commented in surveys that a separate laundry room would improve the service; however there is no space for this in the current layout. The sink in the laundry area was dirty and no soap was available for hand washing. The manager addressed this immediately, and explained staff had not had time to do the usual cleaning as they had gone out with people living at the home. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 21 Generally the home was free from offensive odour and reasonably clean and hygienic. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 22 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience good quality outcomes in this area. People are supported by a competent and caring staff team. Robust recruitment procedures protect the people living at the home. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Of five care staff, two have achieved NVQ level 2 in care, one has level 3 and one is currently working towards level 3. The newest member of staff is due to start her NVQ soon. All four staff that completed a survey said that they had received training relevant to understanding the needs of people living at the home. Staff were observed to support people with getting their breakfast. Staff presented as respectful and caring and seemed to have a good rapport with the people living at the home. People said that they got on well with the staff, and two said that they like their keyworkers. Comments received from staff about what the home does well include; “the running of the house is tailored around each individual service user, we operate to their needs; Residents Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 23 wishes and requests dictate how the home is run; I feel that we support the service users to a high standard”. A comment from a visiting professional in response to ‘what does the home do well?’, “general day to day care. Meeting clients needs to the best of their ability with staff and resources at their disposal”. Three staff files were seen and all contained all the required employment records, including written references and Criminal Records Bureau checks. Evidence of induction training was seen, along with evidence that relevant training had been completed. This included movement and handling, fire training, protection of vulnerable adults, food hygiene, diabetes and epilepsy awareness. Formal supervision had not taken place at the recommended interval of every two months; however the manager has assured the commission since the visit that this will be addressed immediately. The manager reported that the staffing levels are adequate, although recruiting a cleaner may free up staff time to spend more time with people living at the home. Three staff who completed the survey said there are usually enough staff on duty and one said there is always enough staff. A visiting professional commented that “staffing levels at busy periods and weekends should be higher”. Staff and the manager said that there is only sufficient time for staff to support the two people living in the bungalow to cook once a week. The remainder of the time, meals are provided from the main house. The manager has notified the Commission since the inspection visit that she will be exploring the levels of support needed to enable the people in the bungalow to lead a more independent lifestyle; this may involve re-assessing staffing levels. There are currently two staff on duty per shift, and one member of staff sleeps at the home overnight. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 24 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. This is what people staying in this care home experience: JUDGEMENT – we looked at outcomes for the following standard(s): People using the service experience adequate quality outcomes in this area. The home is generally well managed by an experienced manager. The health, safety and welfare of people who live at the home are not always protected adequately. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: Since the last inspection visit, the manager has applied to the Commission to become registered, and this process is complete; the certificate had not arrived at the time of the visit. The manager was a registered nurse, although her registration lapsed some years ago. She is completing the Leadership and Management for Care Services Award and said that she expects to have Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 25 completed this by February 2010. The manager said that she attends regular training relevant to her role as manager. The home has a quality monitoring system in place. The manager says in the AQAA that annual quality assurance questionnaires for residents and stakeholders are completed. People spoken to during this visit said they are listened to by staff and there are residents’ meetings held on a monthly basis; minutes of these meetings were seen. As part of the inspection in order to provide information to help us form judgments about the quality of the service, the manager was asked to complete an annual quality assessment (AQAA) document. This she did, and the document provided the Care Quality Commission (CQC) with a lot of information about the way the home is run, and what they hope to achieve in the future. The AQAA states that all staff have received all mandatory training, and all staff records that were seen confirmed this. The AQAA states under ‘what we do well’, that health and safety standards are maintained and that they are good at hazard reporting. However, concerns about staffs’ awareness of hazards were identified during the visit. As previously mentioned, the shower in the bathroom in the bungalow had been broken. Maintenance records were seen and an entry of “needs new shower. Don’t use will electric shock”, had been made. Records suggested that the shower remained in this state of repair for five days, when a plumber came to replace it. The staff communication book asked staff to tell people living at the home not to use the shower. There was no evidence that any immediate action had been taken to reduce the risk of electric shock. The manager explained that she had been on holiday at the time and was unaware of the situation. At the time of the visit, the shower had been replaced, although was waiting to be wired up. The front of the new shower was missing, exposing the wires. The manager explained that the electrician was scheduled to complete the installation the following day; she has since confirmed that the shower is now working. The mechanism that would allow staff to lock the bathroom door from the outside was broken on the day of the visit. A notice was put on the door to tell people not to use it until the shower had been fixed and following the visit the manager said she sealed off the bathroom. The manager said that she was not aware that the shower had been left without the cover on the front. Better awareness of the health and safety of people living and working at the home is required. There needs to be systems in place to ensure that hazards are identified and dealt with at the earliest opportunity and that there is always staff on duty that are competent in assessing risks to people. A requirement has been made regarding these matters. The manager has taken these Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 26 concerns seriously; since the inspection visit, she has submitted an action plan to the Commission which states that she has discussed this with all staff, and that further training in health and safety, risk assessment and hazard reporting will be provided to staff by the end of August. All accidents and injuries to people living at the home have to be reported to the Commission in order to comply with the Care Homes Regulations 2001. Whilst some have been, it was found that a number of incidents had not been reported appropriately. So that people at the home are protected from harm or abuse, it is a requirement that the Commission be notified of any such incidents and that they are referred in line with safeguarding procedures. The AQAA indicates that health and safety checks are carried out at the required intervals; evidence of this was seen in the records. Once a month a senior manager of the organisation has visited the home to make sure it is being properly managed. These are called Regulation 26 visits, and a report of the visit is kept. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 27 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 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 x Version 5.2 Page 28 Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc 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 YA23 YA42 Regulation 13(6), 37 Requirement To protect people from harm or abuse, incidents of physical assault must be reported and referred under safeguarding procedures. So people are protected from harm, - as far as reasonably practicable, all parts of the home must be kept free from hazards to their safety; - Unnecessary risks to the health or safety of people living at the home must be identified and so far as possible eliminated. Timescale for action 28/08/09 2 YA42 13(4)a,c 28/08/09 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 Refer to Standard YA19 Good Practice Recommendations So that an individual’s health needs can always met without unnecessary delay, a prescription for pain relief DS0000026345.V376938.R01.S.doc Version 5.2 Page 29 Huddersfield Mencap 5 should be requested as per the community nurse’s advice. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 30 Care Quality Commission Yorkshire & Humberside Region Citygate Gallowgate Newcastle Upon Tyne NE1 4PA National Enquiry Line: Telephone: 03000 616161 Email: enquiries@cqc.org.uk Web: www.cqc.org.uk We want people to be able to access this information. If you would like a summary in a different format or language please contact our helpline or go to our website. Copyright © (2009) Care Quality Commission (CQC). This publication may be reproduced in whole or in part, free of charge, in any format or medium provided that it is not used for commercial gain. This consent is subject to the material being reproduced accurately and on proviso that it is not used in a derogatory manner or misleading context. The material should be acknowledged as CQC copyright, with the title and date of publication of the document specified. Huddersfield Mencap 5 DS0000026345.V376938.R01.S.doc Version 5.2 Page 31 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!