Inspection on 24/07/07 for Mountjoy

This inspection was carried out on 24th July 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Mountjoy 05/09/06

Mountjoy 24/01/06

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 Helen Battle Key Unannounced Inspection 24th July 2007 09:55 Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Mountjoy Address 24 Mountjoy Road Edgerton Huddersfield West Yorkshire HD1 5PZ 01484 432471 01484 667747 Imacdonald@bridgewoodtrust.co.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) Bridgewood Trust Limited Miss Joanne Richards Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th September 2006 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 people, however, one of the bedrooms is a double room and as all the people who live in the home occupy single rooms, only seven people are in residence. All of the bedrooms are personalised reflecting peoples’ 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. The manager informed the Commission for Social Care Inspection on 24 July 2007 that the fees range from £286.00 - £473 per week. There are additional charges for hairdressing, holidays and toiletries. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this key inspection a visit to the home took place. The inspector, Helen Battle, visited the home unannounced from 09.55hrs to 15.00hrs. Whilst at the home, key documents such as care assessments, care plans, daily records and the staff records were looked at, and so were the rooms and garden. One member of staff was spoken with, along with the registered manager. Four people living at the home were spoken with. The manager had been asked to complete a questionnaire with information about the service, the people who live at the home, and the staff working at the home. This was returned to the Commission prior to the visit taking place. Surveys were sent to all seven people living at the home, their families and GPs. Three responses were received from people living in the home. All were positive and indicated that staff listen to people and act on what they say, and that people feel comfortable in speaking to staff if they are unhappy about anything. Six surveys were returned from relatives, and one from a GP. All were positive. Comments included: “There has NEVER been any reason to complain. My relative is looked after really well.” “Supports my relative in all activities.” “They listen to what my relative says with patience, then they come up with a solution which my relative understands and is happy with. Mountjoy also support me and my family as relatives. I can always contact Mountjoy to talk. My relative considers Mountjoy as her home, I can never thank Mountjoy enough. “We are made welcome when we visit”. They look after the care and welfare of people who live there extremely well. They treat people as individuals, giving help and encouragement, to attain their full potential.” “Both the staff at Mountjoy and the management of Bridgewood work hard to provide a good life for the residents.” What the service does well: People have a plan of care which addresses their needs and how they are to be met. People have varied and active lifestyles and are supported to undertake activities and maintain friendships and relationships. Relatives of people living in the home are included in people’s lives, where this is chosen. People living in Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 6 the home are supported by a staff team who provide a consistent standard of care. The atmosphere in the home is friendly and relaxed, with people who live in the home evidently comfortable and confident in the company of staff. People living in the home generally get on well together and have established friendships. 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. The summary of this inspection report can be made available in other formats on request. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People are properly assessed before moving into the home with the assurance that their needs will be met. EVIDENCE: No one new has moved into the home since 1996. However, a policy and procedure is in place regarding admissions, and the manager gave assurances that these would be followed should someone need to move to the home. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 9. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. Care plans reflect peoples’ current needs including the decisions they make and the risks they take whilst living their life. EVIDENCE: The care records of two people living at the home were examined. These were generally well detailed and did reflect the current needs of the individuals. However, some of the documents looked at had not always been dated and signed, so it was impossible to ascertain when a change had been made and by whom. Entries in the daily records are descriptive of how people have spent their day and what care and support has been delivered. Four people living at the home were spoken with at length and generally were satisfied with the care and support provided. All four stated that the staff are very good to them and that they are kind and patient. The support given by staff at the home to enable people to make choices and take risks is good. This was spoken about by people living in the home and referred to in the responses in the surveys. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 10 Evidence of this was also seen in care records. Risk assessments and care plans are in place regarding challenging behaviour, to enable staff to meet peoples’ needs in a consistent manner. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People living in the home take part in activities of their choice and are part of the local community. Appropriate relationships are maintained. Peoples’ rights and responsibilities are respected. Meals provided at the home are of a good standard. EVIDENCE: People living in the home take part in a variety of activities suitable for their needs. On the day of this visit, people were seen to be spending time in various parts of the home reading, watching television, listening to music and doing chores. People living in the home attend a variety of day centres, clubs and activities. These include ten pin bowling, horse riding, art class, horticulture, swimming, computer course, and visits to places such as an icecream parlour and garden centre. The people living in the home recently enjoyed a five day caravanning holiday to Cleethorpes with the support of staff. Plans are also being made for a weekend break to Blackpool later in the Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 12 summer. People are supported to maintain their spiritual beliefs with evidence of people attending places of worship on a regular basis where they want to. The gardens are easily and freely accessed by people. People were seen to be treated with respect and their privacy and dignity maintained by staff during this visit. People are supported to maintain links and relationships with friends and family where possible. People who spoke with the inspector stated that they are allowed to see visitors at any time and the home has evidently worked hard with people to support them with maintaining relationships. The meals at the home are good. Feedback from people living at the home was very positive. The menu indicates that there is a good variety of nutritious food, and some people were seen to be enjoying their lunch during this visit. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People receive support in a way they prefer and require and their emotional and health needs are met. People living in the home are protected by the home’s policy and procedure for dealing with medication. EVIDENCE: People spoken to stated that the staff are kind and provide personal assistance in a discreet manner which promotes privacy and dignity. One person said that they could talk to staff if they are upset or crying. People also stated that they are able to choose what times they get up and go to bed. There was evidence in the care records that support is also provided from specialist nurses. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 14 The medication of two people was checked and both were found to tally with the records held. There has been a review of the policies and procedures regarding the management of self medication at the home and this has made a vast improvement to the system and in promoting the safety of people self medicating. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence including a visit. Generally, people feel their views are listened to and acted on. People are not adequately protected from abuse, neglect and self-harm. EVIDENCE: The people who spoke to the inspector indicated that they could speak to any member of staff and that they would be listened to. There have been no formal complaints made to the home since the last visit. The complaints procedure is available for all the people who live in the home and is also written in symbol form for those people who use this type of communication. The details of the Commission should be updated to reflect the current address. Not all staff have had safeguarding training (adult protection). Concerns were raised by the inspector regarding staff understanding of this issue and the manager stated that the planned training in the year would be brought forward to ensure staff have the correct training and understanding. The personal monies of all the people living in the home one person were checked and all but one were found to reconcile with the records held. This was traced to a basic administrative error which was rectified immediately. Lockable facilities are available in people’s rooms for valuables. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30. People who use the service experience excellent quality outcomes in this area. We have made this judgement using a range of evidence including a visit. The people live in a comfortable and safe environment. The home is clean and hygienic. EVIDENCE: The accommodation at Mountjoy is maintained to an excellent standard. All the rooms seen were well decorated and furnished. The home is immaculately clean, and people living in the home were proud to show the inspector around the home and their own rooms. All the bedrooms seen were highly personalised and people evidently take great pride in their surroundings. The home should be commended on the standard of the accommodation. The grounds are also well maintained and accessible by people living in the home. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 and 35. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People are supported by generally competent and qualified staff, and are protected by the home’s recruitment practices. Staff are receiving most mandatory training within recommended timescales. EVIDENCE: All the staff working at the home have received movement and handling training within the last 12 months. The next planned phase of this refresher training is to be implemented in October 2007. As stated earlier in this report adult protection training needs to be given to all staff within two months of this visit and their understanding checked in order to ensure people are properly protected. NVQ (National Vocational Training) training is also continuing at the home with 60 of care staff having achieved NVQ level 2 in Care. Other training includes health and safety, infection control, managing aggression and violence, dementia care, autism awareness and basic food hygiene. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 18 Staffing levels are provided to meet the needs of the people who live in the home and are flexible to take into account the activities and day centre commitments of people. The recruitment process at the home protects the people living there. The records for two members of staff were examined and contained the required information and checks. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. People who use the service experience good quality outcomes in this area. We have made this judgement using a range of evidence including a visit. People benefit from a well run home. Peoples’ views underpin development at the home. The health, safety and welfare of people are protected. EVIDENCE: The manager of the home is experienced in looking after people with learning disabilities. She is currently working towards the NVQ level 4 award in care management. Peoples’ views are listened to and underpin any development of the home’s policies and practices. Monthly management visits are carried out and the provider consults with the people living in the home. Discussions took place with the manager about quality assurance, which takes place at the home. Weekly audits are carried out on medication, personal monies, and monthly Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 20 checks of the accommodation. Staff meetings take place monthly and people who live in the home have a meeting every two to three months. Questionnaires are sent out to people living in the home and their relatives at each individual’s annual review. Plans are being made to formalise the quality assurance carried out in the home. Weekly tests of the fire alarm and emergency lighting system were seen to be recorded as being carried out. An issue was raised during this visit regarding substances which are subject to COSHH (Control Of Substances Hazardous to Health) Regulations. Some cleaning products were not stored safely and the manager agreed to address this issue immediately. All staff have received a fire safety update in May 2007. Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 21 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 4 25 X 26 X 27 X 28 X 29 X 30 4 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 Mountjoy DS0000026324.V343156.R01.S.doc Version 5.2 Page 22 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. 2. Standard YA23 YA42 Regulation 13(6) 13 (4)(a) Requirement All staff must become competent in safeguarding (adult protection). Substances subject to COSHH Regulations must be stored safely. Timescale for action 30/09/07 24/07/07 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 YA6 Good Practice Recommendations Care documentation should be dated and signed by the author. 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