Inspection on 05/09/06 for Mountjoy

This inspection was carried out on 5th September 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 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 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 Karen Summers Unannounced Inspection 5th September 2006 8:30 Mountjoy DS0000026324.V304268.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.V304268.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.V304268.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 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.V304268.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th January 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 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. Fees at the home start at £287.07 - £473 per week. Items not covered by the fee include: Hairdressing, toiletries and holidays. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a key inspection, which included an unannounced site visit on the 5th September 2006, and the duration of the inspection was 6.25 hours. There were 4 service users in residence on the day. Mrs Elaine Taylor, support officer, was present at the inspection, and later joined by Ms Joanne Richard, manager. The following areas were looked at and have been used in the production of this report; a sample of records, care plans, medication, individual discussion with 4 service users, two members of staff, partial tour of the premises and document reading. To reflect the views of those who use the service, satisfaction questionnaires were sent to: 7 service users, 5 were returned; 7 relatives/ advocate/ friend, 2 were returned, and GP’s and district nurses, none were returned. The inspector would like to thank those who contributed to the inspection process, and also thank Mrs Taylor, Ms Richard, her staff and service users, for their time and hospitality on the day of the visit. What the service does well: What has improved since the last inspection? The care records are written in ink and not pencil, and the information recorded in risk assessments has improved. There are medication policies/procedures to ensure that the health and safety of residents are protected. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 6 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 DS0000026324.V304268.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.V304268.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,4 & 5 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. No service user moves into the home without having had his/ her needs assessed and been assured that those needs will be met. 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 1996 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. One of the questionnaires received from service users stated; “I went to visit the home, before I decided to move.” Once the manager was satisfied that they could meet the service users 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 DS0000026324.V304268.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users personal and social care needs are set out in an individual plan. They make decisions about their lives with assistance as needed, and are supported to take risks as part of an independent lifestyle. EVIDENCE: The care records were a good standard, and included risk assessments, goals/ needs, and the likes and dislikes of the service user, and there was also evidence to suggest that the documents had been reviewed and updated. Without exception the questionnaires received from relatives stated that they are kept informed of important matters affecting their relatives/ friends, and that where appropriate they are consulted about their care. One person said that when their relative had to stay in hospital for 2 days, the staff from the home stayed with them. She also said that her relative is very happy and well looked after. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users take part in appropriate activities, and are part of the local community. Service users are encouraged to maintain contact with their family and friends. Service users receive a varied diet that takes into account their likes/ dislikes and dietary needs. 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. A questionnaire received from a service user stated; “I do Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 11 jigsaws sometimes during the day, I watch television in the evening, I go home every other weekend.” The week of the visit one of the service users were celebrating a special birthday and they said that they had chosen to spend their birthday with a small group of friends, whilst another service user whose birthday is later this month, said that he would like a large party with his friends, and both occasions are being arranged by the staff on their behalf. The menu was varied and took into consideration the likes and dislikes of service users. One service user commented that they had enjoyed their lunchtime meal that one of the members of staff had made for them. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 - 20 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Until staff record the outcome of the care/ support given to the service users there is no evidence to suggest that their needs have been met. Service users are protected by the home’s policies and procedures for dealing with medicines, and medication housekeeping was of a good standard. EVIDENCE: Please also refer to standard 6 regarding care records. The care records were a good standard, and included the personal support that the service user receives, and there was evidence to suggest that the documents had been reviewed and updated. The daily record however, should be written in more detail, as at the present time numbers are used to refer to the goals/ needs, and there is no evidence to show what care/ support has been given each day. Medication housekeeping was of a good standard, and there are policies/ procedures to ensure that the health and safety of residents are protected. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and their relatives 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 has abuse awareness training, and there is also an adult protection procedure, which includes whistle blowing. The home needs to have a more up to date Kirklees Protection of Vulnerable Adults Policy. Four out of five relatives/advocates questionnaires stated that they were aware of the complaints procedure, and service users questionnaires stated that they knew who to speak with if they were not happy. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is in a good state of repair and decorative condition, and service users’ individual needs are met in a comfortable and homely setting. The premises are clean and systems are in place to control the spread of infection. EVIDENCE: The home continues to be in a good state of repair, with bedrooms individualised to reflect the interests and personalities of the service users. The premises were clean and systems are in place to control the spread of infection. The service user satisfaction questionnaires commented that the home was always clean. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 15 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, 34 & 35 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing levels and skill mix were sufficient to meet the number and needs of service users, and appropriately trained staff supports service users. Service users are supported and protected by the home’s recruitment practices. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home, and relative’s questionnaires stated that there are always sufficient numbers of staff on duty. 60 of care staff have achieved an NVQ level 2 or equivalent. In relation to recruitment, the staff files contained the relevant information and documentation. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 16 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, 39 & 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The registered manager is of good character and competent to manage the home. 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 drills and training, staff and service users could be potentially at risk in the event of a fire. Without all staff having movement and handling training staff and service users could potentially be at risk of being injured. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 17 EVIDENCE: Ms Joanne Richards, the manager, has a number of year experience in the care of people who have learning disabilities, and she has commenced an NVQ level 4 in management and care. 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. The company has attained a quality of assurance certificate of registration for ISOQ001. One of the questionnaires received by the Commission from a relative commented that the staff are caring, understanding, and the home is a creative place for their relative. Fire alarms and emergency lighting are tested/checked each week and records are kept. Fire drills also take place monthly however; the new member of staff and one other staff had not had a drill. Following the inspection the manager contacted the Inspector to confirm that the two staff had had a drill. All staff should have a minimum of two drills per year. Following the last inspection in January 2006, 5 out of 6 staff had a fire lecture. The new member of staff had one in July, and the manager who has returned from maternity leave has yet to have a lecture. All staff should have a minimum of two lectures a year. In relation to movement and handling, the training records showed that the new member of staff has recently had training. There was no evidence in any of the other staff records to show that they had had any training. At the time of the visit the manager arranged movement and handling training for all the staff. Depending on the risk assessments of the service users, all staff should have movement and handling updates annually. Five staff have had first aid training, and all staff have had basis food hygiene training. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 18 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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 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 2 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 2 2 3 X 2 X 3 X X 1 X Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 19 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA42 Regulation 23.-(4)(d) Requirement “(d) make arrangements for persons working at the care home to receive suitable training in fire prevention…” The manager must have a fire lecture. Please confirm in writing by 09/10/06 when this will take place. Timescale for action 09/10/06 2. YA42 23.-(4)(e) 3. YA42 13.-(5) “(e) to ensure, by means of fire 11/09/06 drills and practices at suitable intervals, that the persons working at the care home and, so far as practicable, service users, are aware of the procedure to be followed in case of fire….”, The registered manager confirmed that all staff had had a fire drill following the inspection. 05/10/06 “The registered person shall make suitable arrangements to provide a safe system for moving and handling service users.” All staff must have movement and handling training. The manager arranged the training at the time of the inspection. 05/10/06 DS0000026324.V304268.R01.S.doc Version 5.2 Page 20 Mountjoy No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard YA6 YA19 YA18 YA23 YA37 YA42 YA42 YA42 Good Practice Recommendations Care documentation should be dated and signed by the author. The daily record should show the outcome of the planned care/ support/ behavioural management etc., and how the carer has honoured their duty of care. The Kirklees Protection of Vulnerable Adults Policy should be replaced with up to date documentation. Standard 37.2 - The manager should have an NVQ level 4 in management and care or equivalent. All staff should have two fire lectures a year. All staff should have a minimum of two fire drills a year. All staff should have annual movement and handling training. Mountjoy DS0000026324.V304268.R01.S.doc Version 5.2 Page 21 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.V304268.R01.S.doc Version 5.2 Page 22 - 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!