Inspection on 22/08/05 for Mountjoy

This inspection was carried out on 22nd August 2005.

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

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

Other inspections for this house

Mountjoy 24/07/07

Mountjoy 05/09/06

Mountjoy 24/01/06

Mountjoy 21/03/05

Mountjoy 12/10/04

Mountjoy 29/03/04

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 MOUNTJOY 24 Mountjoy Road Edgerton Huddersfield HD1 5PZ Lead Inspector Karen Summers Unannounced 22 August 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Mountjoy Address 24 Mountjoy Road Edgerton Huddersfield HD4 7NN 01484 432471 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Bridgewood Trust Limited Miss Joanne Richards Care Home 8 Category(ies) of Learning Disabilities registration, with number of places MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate Date of last inspection 21st March 2005 Brief Description of the Service: 24 Mountjoy Road is owned and managed by Bridgewood Trust, and it is an organisation that specialises in providing accommodation for adults with a learning disability. The home is registered to provide accommodation and care for up to eight service users, however, one of the bedrooms is a double room and as all service users occupy single rooms, only seven service users are in residence. All of the service users bedrooms are personalised reflecting their individual tastes and hobbies. The establishment is a Victorian property and is situated in a residential area, close to the town centre of Huddersfield. The property is well maintained throughout and is indistinguishable from neighbouring houses. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an announced inspection at 24 Mountjoy Road on Tuesday 22nd August 2005, commencing at 9.45 am, and the duration of the inspection was 5.5 hours. The manager, Ms J Richards, was present at the inspection. The following methods have been used in the production of this report: sampling of records, care plans, individual discussion with 2 service users, 1 member of staff, the Operations manager, tour of the premises and document reading. What the service does well: What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2,3 & 5 No service user moves into the home without having had his/her needs assessed. Prospective service users have an opportunity to visit and assess the quality, facilities and suitability of the home. EVIDENCE: The home has not had a new admission since it opened however, the manager, Ms Richards confirmed that a pre admission assessment would be carried, and the prospective service user would be invited to tea and then an overnight stay before making any decisions to live there. Once the manager was satisfied that they could meet the service user’s needs then they would be offered a place at the home. Each service user has an individual contract of terms and conditions with the home. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7 & 9 Service users know their personal goals and these are reflected in their individual plan however, their needs in respect of health and welfare are not identified or reported upon and therefore potentially are not met. Also the risks assessments are not written in sufficient detail, which could also potentially be placing the service user at risk. EVIDENCE: Goals and risks had been identified in the service user’s plan and the goals had been reported upon weekly. The needs in relation to the service users learning disability, and activities of daily living had not been identified or reported upon, and risk assessments had not been written in sufficient detail to show what steps would be taken to minimise the risk and the outcome/ implications. There should also be a daily record that shows the outcome of the planned care/ behavioural management etc. The company have plans to introduce new care documentation in the near future with a view to addressing these issues. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, 16 & 17 Service users are part of the local community. Service users are encouraged to maintain personal and family relationships. EVIDENCE: Service users are encouraged to develop and maintain independent living skills, and also participate in a wide range of social and recreational activities. Monday to Friday service users attend various community activities e.g. college resource centres and Bridgewood Trust horticulture and craft centre. Service users are encouraged and supported to maintain contact with their relatives and friends, and observed to have established relationships between staff and other service users. One of the service users who were spoken with on the day was enthusiastic when she commented on how she had enjoyed her day out shopping, and visiting a pet shop. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 10 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Until the new documentation has been introduced it is not possible to confirm that the physical and emotional needs of service users are met, nor is it possible to confirm that service users receive personal support in the way they prefer and require. Until the documentation in relation to self-medication is revised, service users who wish to self-medicate are potentially not protected by the home’s procedures for dealing with medicines. EVIDENCE: Please also refer to standard 6. The company plans to introduce new care documentation in the near future which will hopefully record in greater detail how service users receive personal support and ensure that their physical and emotional health needs are met. The medication records were correct however, the documentation in relation to a risk assessment, and as to how a service user may retain, administer and control their own medication needs to be written in greater detail. None of the present service users administer their own medication. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 11 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Service users and their relatives and friends can be confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: There is a complaints procedure in the service users guide and the document is produced in both “widget” and written word format. The procedure to follow should a service user wish to make a complaint is discussed periodically in detail, at the residents meetings. There have not been any complaints recorded since the last inspection. All staff have abuse awareness training, and there is also an adult protection procedure, which includes whistle blowing. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 12 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 Service users live in a well-maintained and homely environment. EVIDENCE: The home has recently been redecorated throughout, and is also in a good state of repair. Bedrooms are all individualised to reflect the interests and personalities of the service users. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 13 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 & 36 The staffing levels and skill mix were sufficient to meet the number and needs of service users. By the end of December 2005, there will be a minimum ratio of 50 of care staff having an NVQ level 2 or equivalent. Service users are supported and protected by the home’s recruitment policy and practices. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users living at the home. 40 of care staff have achieved an NVQ level 2, or equivalent, and the company plan to meet the recommended standard of 50 of staff having the qualification by the end of December 2005. In relation to recruitment, the staff files contained the relevant information and documentation. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 14 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 & 42 In relation to the views of the service users, they can be confident that the home is run in their best interest. Without all staff having up to date fire training, staff and service users could be potentially at risk in the event of a fire. EVIDENCE: Prior to the service users six monthly review, they are assisted by either a manager from another home, or an advocate to complete a satisfaction questionnaire. The questionnaire is then discussed and any appropriate action taken. Four service users comment cards and five relatives/ visitors comment cards were returned to the Commission and they commented favourably about the care that they/ their relative receive. Comments included; “My brother is very happy there.” “The continuous care my sister receives is excellent.” “The home has an excellent standard of hygiene and has a happy and relaxed atmosphere.” The company also attained a quality of assurance certificate of registration for ISOQ001 in February 1994 – January 2006. Not all staff have had up to date fire lectures. All staff should have a minimum of two fire lectures per year. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 15 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 3 3 x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 1 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 3 3 Standard No 31 32 33 34 35 36 Score x 2 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 MOUNTJOY Score x 1 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 1 x J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 16 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 6 & 19 Regulation 15.-(1) Requirement The service users plan must set out their needs in respect of their health and welfare, and show how those needs are to be met. Staff to receive suitable training in fire prevention. Timescale for action 1st October 2005 2. 42 23.-(4)(d) 1st October 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. Refer to Standard 6 9 20 32 42 Good Practice Recommendations There should be a daily record that shows the outcome of the planned care/ behavioural management etc., and how the carer has honoured their duty of care. Risk assessment need to be written in greater detail to show the potential risk, how that risk is to be minimised and the perceived outcome. The medication risk assessment, and how a service user may retain, administer and control their own medication should be written in greater detail. A minimum ratio of 50 trained members of care staff to achieve an NVQ level 2 or equivalent, by 31st December 2005. All staff should have two fire lectures per year. MOUNTJOY J51J01_s26324_Mountjoy_v236625_220805.doc Version 1.40 Page 17 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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