Inspection on 20/09/05 for St Anne`s (Huddersfield)

This inspection was carried out on 20th September 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 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

St Anne`s (Huddersfield) 10/12/08

St Anne`s (Huddersfield) 22/01/07

St Anne`s (Huddersfield) 24/02/06

St Anne`s (Huddersfield) 04/01/05

St Anne`s (Huddersfield) 07/07/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 St Anne`s (Huddersfield) 3 Heaton Road Huddersfield West Yorkshire HD1 4HX Lead Inspector Jacinta Lockwood Unannounced Inspection 20th September 2005 10:15 St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 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 St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 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. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service St Anne`s (Huddersfield) Address 3 Heaton Road Huddersfield West Yorkshire HD1 4HX 01484-435571 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) St Anne`s Community Services Mrs Margaret Bedford Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can provide accommodation and care for one named service user at 3 Heaton Road - category PD 4th January 2005 Date of last inspection Brief Description of the Service: St Anne’s (Huddersfield) is the collective name for a project of three houses registered to provide residential care to adults with enduring mental health needs. The project is managed from Heaton Road and the registered manager oversees all three houses. There are two deputy managers, one of whom oversees two houses and one who is based at the largest of the three homes. Each house has their own staff team with some flexible working across the three houses. Cambridge Road, the larger of the homes was purpose built and provides single bedroom accommodation for up to ten people over two floors. It is close to the centre of Huddersfield. Heaton Road provides accommodation for up to six people and is some distance from local amenities. Beech Street, which is close to local amenities, provides accommodation for up to four people. Both date from Edwardian times and provide single bedroom accommodation over four floors. Each of the three houses has communal facilities and gardens. Public transport is within walking distance of all three houses which are located in residential areas St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to an unannounced inspection carried out by one inspector on 20 September 2005. It started at 10.15 and ended at 18.45. The deputy manager of Heaton Road and Beech Street and the registered manager were present for part of the inspection. The following inspection methods were used: discussion with service users, staff and management. Inspection of a sample of documents, including: preadmission documents, care plans, risk assessments, medication, minutes of service user meetings, complaints records, staffing rota, staff records including training, health and safety documentation, some policies and procedures. A limited tour was also made of each building. The inspector would like to thank service users, staff and management for their time and hospitality throughout the inspection. What the service does well: Detailed pre-admission assessment information is obtained before a service user is offered a place at the care home. This information forms the basis of the service user’s plan, which is discussed and agreed with them. Staff have a good understanding of service users’ support needs and a range of professionals meets service users’ healthcare needs. Service users are supported to lead independent lifestyles. They use a variety of communitybased facilities and maintain contact with family and friends. Service users are involved in choosing, shopping and preparing a varied, nutritious diet, which they can take at flexible times in an area of their choosing. A range of relevant training is available to staff to ensure they have the skills and knowledge necessary to support service users. New and agency staff receive a full induction before they begin working with service users. Generally, the houses are well maintained and provide a comfortable and homely environment for service users. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 6 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. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 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 St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 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 Prospective service users’ individual aspirations and needs are assessed before they move into the home. And written confirmation of this is provided to them. EVIDENCE: A community care assessment and a pre-admission assessment was available for recently admitted service users. A third party risk assessment was also obtained prior to admission. These documents provided information which informed the decision to offer accommodation to service users. A letter of confirmation that the home could meet the person’s needs was available on one file. The registered manager explained that such a letter was provided to all service users following assessment. A copy of the letter of confirmation should be available for each service user and could usefully be retained on their file. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 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 Service users are supported to lead independent lifestyles. Service users’ plans reflect their needs and personal goals. EVIDENCE: Care plans for a service user in each of the houses were inspected. A basic care plan was available for a service user recently admitted to Cambridge Road and the registered manager explained that a meeting was to be held the following day to complete a more detailed plan and risk assessments with the service user concerned. The other care plans seen identified the service users’ goals and the daily record clearly linked to the care plan. Service users sign care plans and should they choose not to sign, this is recorded. Service users confirmed that their care plan is discussed with them and that they are involved in reviews. Records show that reviews have recently taken place. An independent advocate supports service users in decision making, where appropriate. Service users confirmed that they are supported to take risks as part of an independent lifestyle. Staff were aware of action to take were a service user to go missing and this is supported by the home’s policy and procedure. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 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, 14, 15, 16, 17 Service users are part of the local community and are able to take part in appropriate activities. Service users are able to develop and maintain relationships and their rights and responsibilities are recognised. A varied and balanced diet is available to service users. EVIDENCE: Service users are able to exercise a good deal of choice in where and how they spend their time. Service users were seen to leave or return to the houses independently. Service users spend their time alone or in company doing ordinary things, such as shopping and visiting the town centre, going to the pub, visiting, or receiving visits, from family and friends, attending day centres, technical college, local cafes and restaurants, sports, attending a place of worship, being a member of a choir. Staff also support service users to engage in activities and service users spoke of having enjoyed summer holidays with other service users and staff. One service user goes cycling with a member of staff. Indoor activities such as arts and crafts, pottery, darts, mini-pool, games, books, music and television are also available. The Licence Agreement sets out rights and responsibilities and service users are supported and encouraged to take responsibility for housekeeping tasks St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 11 and for maintaining their private accommodation. Domestic staff are employed at Cambridge Road and care staff at Heaton Road and Beech Street take responsibility for ensuring the home is clean and tidy. Service users are supported to clean their own rooms. Service users have a key to their room and staff only enter with service users’ permission. Either independently or with support, service users access kitchen facilities to prepare meals. Menus are decided at service user meetings. Staff at Cambridge Road prepare the main evening meal. At Heaton Road and Beech Street, individual service users take turns to shop and cook a meal, with staff support, for others in the house. This provides an opportunity for service users to develop their skills and achieve a degree of independence. Menus were varied and balanced and fresh fruit was readily available. Service users commented positively on the food provided. A service user spoke of having themed meals, such as a curry night, and was looking forward to further themed meals. Nutritional assessments are completed and service users’ weight monitored. The dining area in each of the houses was pleasant. Service users were seen to take their meals at flexible times and in an area of their choosing, such as the lounge, dining room or their bedroom. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 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, 19, 20 Service users receive personal support in the way they prefer and require. A range of healthcare professionals meet service users’ physical and emotional healthcare needs. Service users, where appropriate, manage their own medication. The way medication is managed by staff has the potential to place service users at risk. EVIDENCE: There is a mix of both male and female staff. Staff were seen to interact positively with service users, providing advice and support in a calm, helpful and friendly manner. Service users made positive comments about the support received from staff. It was clear from records and discussion with service users and staff that service users’ physical and emotional health needs are monitored and met by a range of healthcare professionals. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 13 Staff receive accredited medication training. And staff spoke positively about this. The service provider has a comprehensive policy for the management of medication, including self-medication by service users. Where assessed as able, service users manage their own medication. A sample of medication was audited at each of the houses. It was not possible to fully reconcile one medication at Beech Street, as the records were not clear. One medication record at Cambridge Road had gaps in recording the administration of medication and amendments had been made to the timing of administration without clear reasons as to why this amendment was made. It is important that accurate and up to date medication records are maintained to ensure the welfare and safety of service users. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 14 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 Service users are confident that their views are listened to and acted upon. Some systems are in place to protect service users from potential abuse. EVIDENCE: The service provider has a comprehensive complaints policy and procedure. Where complaints have been made, these have been recorded and the issues addressed. Service users knew who to speak to were they to be unhappy about anything and were confident that their concerns would be dealt with. Staff were aware of adult protection issues and adult protection training has been arranged for staff. The service provider has good policies and procedures for the prevention of abuse to vulnerable adults, whistle blowing and appropriate use of restraint. Service users said they felt safe living at the home. Although a recent incident involving two service users had been reported to the police and a service user’s advocate and community psychiatric nurse as well as the Commission, the incident had not been reported to the local authority adult protection team who are the lead authority in adult protection. This was discussed with the registered manager at the time of the inspection. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 15 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 Service users live in a homely, comfortable and generally safe environment. All houses are clean and hygienic. EVIDENCE: All three houses provide a homely and comfortable environment for service users. The décor is bright and the houses receive good natural light. Trees shade the smoking lounge at Cambridge Road. The houses were clean, tidy and odour free. Items of dining and lounge furniture have recently been purchased for Heaton Road and Cambridge Road and are of a good quality. Service users are able to purchase their own furniture in preference to that provided by St Anne’s should they choose to. A vacant bedroom at Beech Street requires redecoration and a new floor covering before anyone is admitted to the home; this was said to be in hand. The back yard at Beech Street was untidy with discarded cigarette ends littering the ground; in parts, the tarmac was covered in moss and poses a potential health and safety risk to anyone walking outside. One half of a gate to an area of garden belonging to Beech Street was hanging off and should be repaired. Paintwork to tiling at the back entrance porch was peeling and looked unsightly. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 16 The floor surface to the laundry at Heaton Road was scuffed and bare in parts and should be repainted for ease of cleaning and to ensure that hygiene standards are maintained. These outstanding works should be included in the home’s programme of routine maintenance and refurbishment and addressed. Systems are in place for reporting maintenance issues. Discussions have been held with relevant parties about the suitability of the environment at Heaton Road for one service user. An assessment report indicates that although, at present, the environment can meet the service user’s needs, the situation should be monitored. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 35 Staff receive appropriate training to ensure they can meet service users’ individual and joint needs. Generally, sufficient numbers of staff with complementary skills are available to support service users. EVIDENCE: Although 50 of staff have not yet achieved the NVQ award, or equivalent, some staff are nearing completion. The deputy manager of Heaton Road and Beech Street is an NVQ assessor and is working with staff to complete their portfolios. The majority of staff spoke positively about the wide range of training provided by the organisation, which has helped them to develop the skills necessary to undertake their caring duties. Recently employed members of staff explained that they had received full induction training before they began to work with service users and that they had been supported by experienced members of the staff team. Staff training records show that nine members of staff have been booked on adult protection training in the near future. Training on Schizophrenia Awareness has also been arranged. Service users said they felt supported by staff. Service users appeared comfortable in approaching staff and staff responded appropriately to service users’ requests for information and support. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 18 Staffing levels at Heaton Road and Beech Street were adequate for the needs and numbers of current service users. The staffing rota for Cambridge Road showed that during one week the staffing hours provided fell below the minimum staffing level provided by St Anne’s (Huddersfield). The following week the hours provided were above the minimum. However, minimum staffing levels must be maintained and a requirement is made. The registered manager’s hours are supernumery. The registered manager explained that there are two vacancies across the team and interviews were to be held shortly. In the mean time agency staff are used to cover vacancies. The registered manager also explained that the same members of agency staff are used where possible and all receive induction training before they begin to work with service users. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 42 The registered manager is qualified and experienced to run the home. Generally, systems are in place to ensure a safe working and living environment is provided for staff and service users. EVIDENCE: The registered manager, Margaret Bedford, is responsible for the three houses and is supported by two deputy managers. The registered manager has a long experience of working in care homes with this service user group and of supported living schemes. She has obtained an NVQ level 4 qualification in care and management and the Registered Manager’s Award. The service provider has up to date work place risk assessments in place. Fire drills and emergency lighting and fire equipment tests are up to date. COSSH records are well maintained. Gas safety checks are carried out. Monthly health and safety checks are undertaken and routine maintenance visits are made to each of the houses. Emergency visits are requested when necessary. The registered manager explained that staff are to receive training St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 20 so they can check that the thermostatic valves to the hot water supply are working properly. Hot water temperature checks are not carried out or recorded at present. This should be addressed. Relevant checks have been made of the cold water storage facilities at Cambridge Road. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X X 1 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 St Anne`s (Huddersfield) Score 3 3 1 X Standard No 37 38 39 40 41 42 43 Score 3 X X X X X 2 DS0000026353.V252871.R01.S.doc Version 5.0 Page 22 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 2 Standard YA20 YA34 Regulation 17(1)(a) Sch3(3)(i) 19&17(2) Sch 2&4 18(1)(a) Requirement Accurate and up-to-date medication administration records must be kept. Staff recruitment records must be kept at the home and be available for inspection. (Timescale of 01.04.05 not met) Minimum staffing levels must be maintained. Timescale for action 21/10/05 31/01/06 3 YA35 21/10/05 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 YA2 Good Practice Recommendations A copy of the letter to the service user confirming that their assessed needs can be met at the care home should be retained on the service user’s file and be available for inspection. Where changes are made to a service user’s medication regime, their doctor’s agreement should be clearly evidenced on the medicines administration record. Adult protection referrals should be made to the local authority adult protection team as appropriate. Maintenance issues identified in the body of this report DS0000026353.V252871.R01.S.doc Version 5.0 Page 23 2 3 4 YA20 YA23 YA30 St Anne`s (Huddersfield) 5 6 YA32 YA42 should be addressed. 50 of the care home’s staff should be qualified to NVQ level 2, or equivalent, by 31.12.2005. The hot water system should be tested for safety in terms of its storage and water temperature at the point of delivery. St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 24 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 St Anne`s (Huddersfield) DS0000026353.V252871.R01.S.doc Version 5.0 Page 25 - 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!