Care Home: Headingley Court

What the care home does well People who lived at the home and their relatives said that they were looked after well. One person told us, "Staff care for people as individuals". Assessments carried out on perspective residents were very detailed and could clearly determine if the home was able to meet their needs.There was a good complaints procedure, which was clear and easy to follow. The surveys returned told us people knew how to make a complaint and felt confident to do so if required. Activities provided for the people who lived in the home were good, two activity co-ordinators were employed and activity programmes seen provided a good variety of activities. People who lived at the home said, "The activities are good we have lots of things to do". The standard of cleanliness throughout the home was maintained to a good standard. What has improved since the last inspection? The care plans clearly identify people`s needs and have measure in place to meet those needs. The care plans were regularly reviewed. Staff told us, "The care plans are much better, they are easy to follow and use, to understand peoples needs". The environmental standards continue to improve, and many rooms have been redecorated. The bathrooms have also been upgraded to provide suitable facilities to meet people`s needs. What the care home could do better: Staff training has been out of date for over a year, this needs to be addressed and appropriate training should be provided. This would ensure staff are able to meet peoples needs. However since the inspection the area support manager has told that a training programme is in place and all staff will have received training by the end of August 2008. CARE HOME ADULTS 18-65 Headingley Court Headingley Way Edlington Doncaster DN12 1SB Lead Inspector Sarah Powell Key Unannounced Inspection 7th July 2008 09:20 DS0000070013.V368359.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 DS0000070013.V368359.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. DS0000070013.V368359.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Headingley Court Address Headingley Way Edlington Doncaster DN12 1SB 01709 866610 01709 866611 headingley@mimosahealthcare.com None Mimosa Healthcare (No4) Limited 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) Post vacant Care Home 25 Category(ies) of Physical disability (25) registration, with number of places DS0000070013.V368359.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care Home with Nursing - code N, to service users of the following gender: Either, whose primary care needs on admission to the home are within the following category: Physical disability - Code PD The maximum number of service users who can be accommodated is: 25 10th July 2007 2. Date of last inspection Brief Description of the Service: Headingley Court is a single storey modern building in Edlington village close to local shops and amenities. The home is purpose built, providing accommodation for adults with physical disabilities. The people living at Headingley Court have many varying conditions. The home has been adapted accordingly, with ramps and wide corridors for easy access. The home is surrounded by pleasant well-maintained gardens and has a large car park. The fees at Headingley Court were £490 - £1006 for further information contact the home. DS0000070013.V368359.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means that the people who use this service experience good quality outcomes. This was an unannounced key inspection and took place on 7th July 2007 at 09:20 and finished at 16:30. The visit included talking with 11 people living at the home, a number of relatives, the new manager, the area support manager and 6 staff. A walk around the building to gain an overview of the facilities and we checked a number of records. Some surveys forms were sent to people who live at the home, their relatives and staff. At the time of this visit nine were completed and returned to the Commission. The comments received were positive. At the time of the visit an annual quality assurance assessment (AQAA) had not been returned, however this was requested at the visit and the manager has since completed this and returned it to us. This focuses on how well outcomes are being met for the people using the service. It also gives us some numerical information about the service. A new manager was in post at the time of the visit, she had commenced at Headingley Court on 23rd June 2008, so had only been in post for two weeks. A staff meeting was held on the day of the visit, which we attended, the manger introduced herself and explained how she intended to continue to move things forward and improve the outcomes for the people who lived there. Feedback was given to the new manager and the area support manager at the end of the visit. What the service does well: People who lived at the home and their relatives said that they were looked after well. One person told us, “Staff care for people as individuals”. Assessments carried out on perspective residents were very detailed and could clearly determine if the home was able to meet their needs. DS0000070013.V368359.R01.S.doc Version 5.2 Page 6 There was a good complaints procedure, which was clear and easy to follow. The surveys returned told us people knew how to make a complaint and felt confident to do so if required. Activities provided for the people who lived in the home were good, two activity co-ordinators were employed and activity programmes seen provided a good variety of activities. People who lived at the home said, “The activities are good we have lots of things to do”. The standard of cleanliness throughout the home was maintained to a good standard. 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. DS0000070013.V368359.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 DS0000070013.V368359.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. This judgement has been made using available evidence including a visit to this service. The assessments clearly identified people’s needs to be able to determine if they could be met. EVIDENCE: We looked at assessments for two people who had recently moved into Headingley court. The assessments, although both used a different format, clearly identified the needs of the person and helped determine that the home could meet these needs. For people referred through care management, there were assessments in the files carried out by the social worker from the placing authority. One local authority assessment we saw was dated October 2007 and he came to live at the home in March 2008. It clearly showed different needs to the homes assessment, which was carried out in February 2008 prior to him moving in. Up to date information is required from the placing authority to determine if their needs can be met. DS0000070013.V368359.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. This judgement has been made using available evidence including a visit to this service. Each person in the home had a plan of care with clearly identified needs, these were met, and people were treated with respect, were able to make decisions about their lives and take risks as part of an independent lifestyle. EVIDENCE: Two people in the home were case tracked and their plans were looked at in detail. The plans had identified the needs of the people with good recordings of the measures to take to meet their needs. The plans were regularly reviewed; people and their relatives were involved in this process. This ensured their views were listened to and their needs met. People spoken to were aware of the plans. The risk assessments were better, risks were identified in the plans of care we looked at to ensure people were protected and their needs met. However one DS0000070013.V368359.R01.S.doc Version 5.2 Page 10 person’s assessment stated that he could have challenging behaviour, yet no risk assessment was in place for this or any charts for recording his behaviour. It was therefore difficult to determine if his needs could be met. People were able to make decisions and choices regarding their care with support from staff. We observed staff giving assistance and allowing people to make choices to ensure their needs were met. One person told us, “Yes I make choices and staff let me do things”. DS0000070013.V368359.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 & 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People exercised choice and control over their daily lives and activities ensuring their needs were met. EVIDENCE: The activity co-ordinators provide good varied activities to meet people’s needs. People told us, “I enjoy the activities they are very good”. There were group activities and 1 to 1 sessions depending on people’s choices and needs. People had also been on holiday this year and more holidays were organised to meet people’s needs. One person told us, “I have been on holiday it was really good”. DS0000070013.V368359.R01.S.doc Version 5.2 Page 12 On the day of our visit the activity co-ordinators were not working and we observed people were still placed in the lounge in front of the television with no other stimulation. This was discussed with the new manager who had already identified this. She had many ideas to improve this and would discuss at further staff meetings, to ensure people’s needs were met at all times. Links with family and friends were encouraged and maintained, a visitor spoken to said, “I can visit at any time and am able to see my relative/friend in the lounge or her room, I also take her out ”. There was a new cook in post she told us she had developed a new menu choice. This was developed in consultation with the residents; she was waiting to discuss this with the new manager and implement as soon as possible, to ensure people’s choices were available. One meal was liquidised, all the food had been put together to create a meal that looked unappetising. This was discussed with the cook who was not aware that different foods should be liquidised separately, but assured us this would be done in future to ensure the meal was well presented. The meals had improved since our last visit all people were taken into the dining room to eat and choices were offered. People told us, “The food is always lovely”. There was good interaction with staff and people throughout the meal, people were having a laugh and a joke with each other and it was a very pleasant atmosphere that was being enjoyed by the people and staff. One person told us, “we always have a good time and I enjoy meal times”. The meals were a relaxed enjoyable time and people showed a good sense of wellbeing. DS0000070013.V368359.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 & 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s health care needs were met and they were supported in the way they preferred. Medication procedures protected people. EVIDENCE: All health care needs of people were met and regular input from health care professionals was obtained. Their advice was followed and well documented in the plans ensuring the wellbeing of the people who lived in the home. People were treated with respect and privacy and dignity upheld. During the visit we observed staff interacting well with people. One person said, “The staff are lovely”. We looked at medication procedures, records were kept of all medicines received, administered and disposed of, which protected people. All staff who administered medication were registered nurses and the manager regularly checked competencies to ensure safety of people. DS0000070013.V368359.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who lived in the home were listed to and protected. EVIDENCE: There was a good complaints procedure that was displayed in the entrance area and this gave clearly defined timescale for action. The home had received five complaints since the last inspection, one of which was annoymous and was received by the Commission for Social Care Inspection and sent to the provider for them to investigate. All the complaints were satisfactorily resolved. There was a good adult safeguarding procedure and the manager also had copies of the local authority’s procedure. Staff we spoke to were aware of the procedure and the importance of safeguarding people from abuse. However staff training in safeguarding required updating to ensure staff were familiar with new local authority procedure. There had been two adult safeguarding referrals since the last visit both incidents were dealt with appropriately and procedures followed to safeguard people. DS0000070013.V368359.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Standard of cleanliness was good and environmental standards continued to improve to provide a homely, comfortable environment for the people that lived there. EVIDENCE: A tour of the building was carried out and the standard of cleanliness observed was very good, providing a clean environment for the people who lived there. There had been considerable improvements to the environment since our last visit and the improvements were continuing, bathrooms were being upgraded to provide facilities, which will meet people’s needs. The floor covering that were marked and stained in bathrooms were being replaced and the bedrooms were gradually being redecorated. This will ensure a good environment is provided for the people. DS0000070013.V368359.R01.S.doc Version 5.2 Page 16 The manager told us some bedroom carpets and curtains were still to be replaced. She also told us some relatives had requested new curtains. When these are replaced it will ensure the environment is maintained to a good standard. DS0000070013.V368359.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 & 35. People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff training was not up to date. Recruitment procedures were robust protecting people who lived at the home. EVIDENCE: Staff training was out of date; this had been out of date at the previous visit and did not ensure staff could meet people’s needs. However the providers have had difficulties getting a training provider, this has now been resolved. A full training programme has been implemented. Since the visit the manager has informed us that the programme will ensure all staff receive training in safe moving and handling, fire awareness, protection of vulnerable adults, food hygiene and health and safety by the end of August 2008. This will ensure appropriately trained staff meets people’s needs. DS0000070013.V368359.R01.S.doc Version 5.2 Page 18 The manager also told us that 12 staff have also been registered on national vocational qualification training level 2 (NVQ) to ensure they are appropriately trained. Recruitment procedures were good. Files seen contained all the required information including criminal record bureau checks, protecting people who lived in the home. DS0000070013.V368359.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. This judgement has been made using available evidence including a visit to this service. Management and administration safeguards people, good health and safety policies and procedures were in place ensuring the safety of people in the home. EVIDENCE: There was a new manager in post she had only been in post two weeks. She was experienced and qualified to run the home. She told us she would apply to the Commission for Social Care Inspection to become the registered manager. DS0000070013.V368359.R01.S.doc Version 5.2 Page 20 Quality monitoring was carried out, regular audits were also carried out and the provider carried out regulation 26 visits, these are visits to gain feedback from staff, people living at the home and relatives. The provider would also look at the environment and care plans and other documentation, which may be relevant. The home had a comprehensive health and safety policy. A new maintenance person had been appointed who was responsible for regular environmental checks and water temperatures checks. We saw these checks they were comprehensive and maintained safety. He had identified that cold water exceeded the safe temperature, the manager was addressing this to ensure peoples safety. We were able to evidence that regular maintenance of equipment and systems was carried out. Risk assessments were carried out on all safe-working practices, regular audits were carried out on the building and all accidents were properly recorded and reported ensuring people in the home were safeguarded. DS0000070013.V368359.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 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Sco2re 31 X 32 2 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 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 3 x DS0000070013.V368359.R01.S.doc Version 5.2 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. Standard YA35 Regulation 18 Requirement All staff training must be updated to meet the needs of the people in the home (Previous timescales not met) Risk assessments must be in place for all people in the home to ensure their safety. Timescale for action 01/09/08 2. YA9 13 01/09/08 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. 2. 3. 4. 5. Refer to Standard YA32 YA2 YA17 YA12 YA24 Good Practice Recommendations It is recommended that 50 of staff achieve NVQ level 2 or above to meet the needs of the people in the home. When assessing perspective new residents an up to date assessment should be obtained from the placing authority. Liquidised food should be liquidised separately to provide a well-presented appetising meal. When activity co-ordinators are not working people should be consulted on their choices and provide alternative The maintenance and renewal programme should continue to ensure a well maintained environment is provided. DS0000070013.V368359.R01.S.doc Version 5.2 Page 23 6. YA42 The cold-water temperatures that exceeded the safe temperature limit should be adjusted to meet the required temperature. DS0000070013.V368359.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000070013.V368359.R01.S.doc Version 5.2 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!