Inspection on 24/01/06 for Mountjoy

This inspection was carried out on 24th January 2006.

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 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

Mountjoy 24/07/07

Mountjoy 05/09/06

Mountjoy 22/08/05

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 West Yorkshire HD1 5PZ Lead Inspector Karen Summers Unannounced Inspection 24th January 2006 08:45 Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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 Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Mountjoy Address 24 Mountjoy Road Edgerton Huddersfield West Yorkshire HD1 5PZ 01484 432471 01484 667747 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) Bridgewood Trust Limited Miss Joanne Richards Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th March 2003 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 DS0000026324.V279781.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection at the home on Tuesday 24th January 2006, and the duration of the inspection was 2.75 hours. All the core standards were assessed during the announced inspection in August 2005, therefore this inspection has covered any requirements and recommendations to be followed up from that inspection. The inspector would like to thank residents and staff for their time and hospitality throughout the inspection. 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. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 Page 6 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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 Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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): EVIDENCE: These standards were not inspected on this occasion. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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): The standards were not inspected however, the requirement/ recommendations from the last inspection were. (Standards 6 & 9) EVIDENCE: New care documentation is in the process of being introduced, and it was comprehensive and a good standard. The documentation had been introduced for one of the service users and staff plan to have all the records changed over to the new paperwork in the next few weeks. The document inspected was in a draft format and had been written in pencil. The records should be written in ink. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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): EVIDENCE: These standards were not inspected on this occasion. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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): The standards were not inspected however, the recommendations from the last inspection were. (Standards 19 & 20) EVIDENCE: Please also refer to standard 6. The new documentation records, in greater detail, how service users receive personal support and ensures that their physical and emotional health needs are met. At the present time staff have introduced the new documentation for one of the service users, and plan to have all the other service users records completed within the next few weeks. At the previous inspection a recommendation was made that the risk assessment in relation to self-administration of medication should be written in greater detail. As this information was not available at the time of the inspection the recommendation will be looked at on the next inspection. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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): EVIDENCE: These standards were not inspected on this occasion. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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): EVIDENCE: These standards were not inspected on this occasion. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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): 32 & 33 The staffing levels and skill mix were sufficient to meet the number and needs of service users. Staff are also trained and competent to do their job. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. 50 of care staff have achieved an NVQ level 2 or equivalent. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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): 37 & 42 The registered manager is of good character and competent to manage the home. 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: Ms Joanne Richards, the manager, and who is currently taking maternity leave, has many years experience in the care of people who have learning disabilities, and she has commenced an NVQ level 4 in management and care. The acting manger, Mrs E Wickenden also has many years experience in the care of people who have learning disabilities, and she too is of good character and competent to manage the home. Unfortunately not all staff have had two fire lectures. Further training has been arranged for all staff to attend in the next two weeks. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 Page 16 A number of service users were spoken with, and without exception they all looked well cared for, and staff and service users were observed to interact very well with each other. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 X 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 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 2 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 1 2 X 2 X X X X 1 X Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 Page 18 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 YA19YA6 Regulation 15.-(1) Requirement Timescale for action 13/02/06 2. YA42 23.-(4)(d) 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. The registered provider should confirm in writing by 13/2/06, when all the service user’s plans will contain the new revised documentation. Staff to receive suitable training 13/02/06 in fire prevention. Fire training has been arranged for all staff to attend in the next two weeks. The registered provider should confirm in writing by 13/2/06 that all staff have had the training. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 Page 19 No. 1. Refer to Standard YA6 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. New documentation is in the process of being introduced. Care records are legal documents and should be written in ink not pencil. 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. New documentation is in the process of being introduced. The medication risk assessment, and how a service user may retain, administer and control their own medication should be written in greater detail. As this information was not available at the time of the inspection the recommendation will be looked at on the next inspection. Standard 37.2 - The manager should have an NVQ level 4 in management and care or equivalent. All staff should have two fire lectures per year. 2. 3. YA6 YA9 4. YA20 5. 6. YA37 YA42 Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Brighouse Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Mountjoy DS0000026324.V279781.R01.S.doc Version 5.1 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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