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Inspection on 10/02/06 for The Letchworth Mental Health Project

Also see our care home review for The Letchworth Mental Health Project for more information

This inspection was carried out on 10th February 2006.

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 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home provides a supportive and structured environment to service users who have a history of mental health issues. Staff are able to closely monitor service users health and ensure that professional assistance is sought should this be required. On the day of the inspection staff were observed motivating a service user to get ready to attend an appointment. Another service user was feeling unwell and staff offered support and reassurance. Feedback from service users about the support they receive was very positive. One service user said `The carers are very helpful, they are very kind and caring.` Care plans observed were person centred. Service users had agreed their care plans, which are regularly subject to review. Service users are encouraged to undertake daily living skills such as cleaning, laundry and cooking. Group house meetings are held regularly where service users can participate in decision making.

What has improved since the last inspection?

The doors to the kitchen cupboards have been replaced offering a bright, clean area for food preparation. Information on individual risk assessments has improved, increasing service users safety.

What the care home could do better:

There was a smoke filled atmosphere on entry to the home, this is due to a number of service users smoking cigarettes in the lounge. Two service users had a made a formal complaint to Granta Housing Society as they were unhappy that they are forced to sit in the smoke filled lounge. Although a response was received, service users were unsatisfied and this continues not tobe resolved. The carpet in the communal lounge has several cigarette burns and must be replaced. The staff office is a small box room, which is also used for staff sleepovers. Service users commented that the dining room is used to accommodate staff meetings. This encroaches on space and confidentiality can be difficult to maintain.

CARE HOME ADULTS 18-65 The Letchworth Mental Health Project 8-10 Springshott Letchworth Hertfordshire SG6 2HJ Lead Inspector Alison Jessop Unannounced Inspection 15th February 2006 10:00 The Letchworth Mental Health Project DS0000019577.V282174.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 The Letchworth Mental Health Project DS0000019577.V282174.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. The Letchworth Mental Health Project DS0000019577.V282174.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service The Letchworth Mental Health Project Address 8-10 Springshott Letchworth Hertfordshire SG6 2HJ 01462 678122 01462 678122 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) Granta Housing Society Limited Miss Amanda Hoy Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5), Mental Disorder, excluding of places learning disability or dementia - over 65 years of age (5) The Letchworth Mental Health Project DS0000019577.V282174.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st October 2005 Brief Description of the Service: Letchworth Mental Health Project provides residential care to five adults who have a history of mental health problems. 8-10 Springshott is two terraced houses that have been converted into one house. The house consists of a lounge, kitchen/diner, utility, one bedroom, a staff sleep-in room/office and a toilet all of which is on the ground floor. On the first floor there are 4 further bedrooms, two bathrooms and a toilet. There is a large garden and patio area with table, chairs and sunshade. The property is situated on a housing estate in Letchworth and is within walking distance to local shopping facilities. Granta Housing Society Limited are the registered provider. The Letchworth Mental Health Project DS0000019577.V282174.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One Regulatory Inspector carried out this Unannounced Inspection over one morning. Three of the five service users were at home whilst two were out attending day services. The atmosphere in the home was relaxed and service users feedback was in the main positive. What the service does well: What has improved since the last inspection? What they could do better: There was a smoke filled atmosphere on entry to the home, this is due to a number of service users smoking cigarettes in the lounge. Two service users had a made a formal complaint to Granta Housing Society as they were unhappy that they are forced to sit in the smoke filled lounge. Although a response was received, service users were unsatisfied and this continues not to The Letchworth Mental Health Project DS0000019577.V282174.R01.S.doc Version 5.1 Page 6 be resolved. The carpet in the communal lounge has several cigarette burns and must be replaced. The staff office is a small box room, which is also used for staff sleepovers. Service users commented that the dining room is used to accommodate staff meetings. This encroaches on space and confidentiality can be difficult to maintain. 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 Letchworth Mental Health Project DS0000019577.V282174.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 The Letchworth Mental Health Project DS0000019577.V282174.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): None of these standards were inspected on this occasion. EVIDENCE: The Letchworth Mental Health Project DS0000019577.V282174.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): 9 & 10 Areas of risk are identified and clear protocols on how to manage risks are included in individual Care Plans, this ensures that all staff working with service users are aware of risks and could potentially reduce or eliminate any future issues. EVIDENCE: A requirement was made during the previous inspection for clear protocols on managing alcohol consumption and diabetes. Clear guidelines have been drawn up and are included in an individual risk assessment. The staff office is a small box room, which is also used for staff sleepovers. Service users commented that the dining room is used to accommodate staff meetings. This encroaches on space and confidentiality can be difficult to maintain at times. The Letchworth Mental Health Project DS0000019577.V282174.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): None of these standards were inspected on this occasion. EVIDENCE: The Letchworth Mental Health Project DS0000019577.V282174.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): None of these standards were inspected on this occasion. EVIDENCE: The Letchworth Mental Health Project DS0000019577.V282174.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): 22 & 23 New house rules that were implemented with the involvement of service users have been circulated to all visitors. Clear boundaries have been introduced to visitors to ensure that service users privacy and safety are protected. EVIDENCE: One complaint had been made to Granta Housing Society by two service users in relation to the homes smoking policy. Although the complainants received a response within reasonable timescales, the complainants were unsatisfied with the contents of the response and therefore the complaint has been upheld. A copy of the Hertfordshire Protection of Vulnerable Adults Procedure was available to staff and all staff have received training on how to deal with any concerns. The Letchworth Mental Health Project DS0000019577.V282174.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): 24 & 30 The atmosphere in the communal lounge was extremely smoke filled and the décor looks nicotine stained. This provides an unpleasant atmosphere to those non-smokers, who have no other communal lounge to use which, is smoke free. EVIDENCE: There was a smoke filled atmosphere on entry to the home, this is due to a number of service users smoking cigarettes in the lounge. Two service users had a made a formal complaint to Granta Housing Society as they were unhappy that they are forced to sit in the smoke filled lounge. Although a response was received, service users were unsatisfied and the complaint has not been resolved. The carpet in the communal lounge has several cigarette burns and must be replaced. The Letchworth Mental Health Project DS0000019577.V282174.R01.S.doc Version 5.1 Page 14 The home has experienced problems with water flow and the manager stated that this continues to be a problem. During the previous inspection a plumber had been called out, as there was no water at all in one side of the house. Although this was resolved on the day, it continues to be an ongoing problem. The Letchworth Mental Health Project DS0000019577.V282174.R01.S.doc Version 5.1 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 Although staff had received mandatory training some of this has not been completed annually. This does not meet Sector Skills Council workforce training targets and fails to meet the National Minimum Standards on Training and Development. EVIDENCE: The Registered Manager has successfully completed her Registered Managers Award and all of the care workers are undertaking NVQ level 2. Staff who work in the home on a temporary basis who usually work in supported living are also being trained to NVQ level 2. Staff files observed demonstrated that staff had received mandatory training during their employment, however, training such as Moving and Handling had not been completed since 2003. Records relating to recruitment were observed to be satisfactory. The Letchworth Mental Health Project DS0000019577.V282174.R01.S.doc Version 5.1 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): 39 & 42 The annual quality assurance survey is available in pictorial format, this enables service users who have a learning difficulties to give feedback. EVIDENCE: The annual quality assurance survey is currently being distributed service users. The results of this must be submitted to CSCI. Service users can also offer feedback during house meetings. Advice had not been sought from the HSE and fire prevention officer in relation to the fitting of window restrictors on the first floor. This was a recommendation from the last inspection report. Risks had been assessed, however it was agreed that window restrictors would be fitted in order to eliminate the risk. The Letchworth Mental Health Project DS0000019577.V282174.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 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 2 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 X X X X X 3 X X 2 X The Letchworth Mental Health Project DS0000019577.V282174.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? Yes 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 YA10 Regulation 12(1)(a) Requirement The Registered Person must ensure that the physical design of the premises provides a smoke free communal lounge to service users. A dedicated smoking area must be implemented which does not encroach on service users communal areas. The carpet in the communal lounge must be replaced. The communal areas of the home must be free from odours such as smoke and nicotine. All care staff in accordance with the Sector Skills Council must complete mandatory training. A window restrictor must be fitted to an identified first floor window. Timescale for action 31/08/06 2. 3. 4. 5 YA24 YA30 YA35 YA42 23(2)(b) 16(2)(k) 18(1)(c) (i) 13(4)(a)& (c) 31/05/06 31/08/06 31/08/06 31/03/06 The Letchworth Mental Health Project DS0000019577.V282174.R01.S.doc Version 5.1 Page 19 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations The Letchworth Mental Health Project DS0000019577.V282174.R01.S.doc Version 5.1 Page 20 Commission for Social Care Inspection Hertfordshire Area Office Mercury House 1 Broadwater Road Welwyn Garden City Hertfordshire AL7 3BQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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