Inspection Report on

Transcription

1 Inspection Report on Highfield A Highfield Park Llandyrnog LL16 4LU Date of Publication 1 December 2016

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3 Description of the service Highfield A is located in a village called Llandyrnog which is near Denbigh. The service is made up of five homes called Ash, Beech, Ivy, Hillside and Cherry. They provide care and support for up to 20 younger adults who have learning disabilities and are aged between 18 and 64 years. Highfield A is owned by Mental Health Care (Highfield Park) Limited. There is a nominated responsible individual for this service. There is no registered manager. A person has been appointed and has put in an application to CSSIW to become the registered manager. Summary of our findings 1. Overall assessment This inspection focused on the non compliance notices issued at previous inspections. We identified these have now been met as improvements have been made. For this inspection we visited Ash. People living there are receiving good care and support from an improving service. 2. Improvements Systems are in place so that people, their relatives and staff can give their views. Staff use a person centred approach and receive training to support individuals complex needs. Ash is being made more homely with attention given to decorating and personalising different areas. A brightly coloured activity room has been completed and is being used by people living in the home. There is a pleasant outside area where people can relax. 3. Requirements and recommendations Section five of this report sets out our recommendations to improve the service further. This includes the need to review policies and procedures to ensure they contain enough detail for staff to clearly understand their roles and responsibilities. People should be actively offered a service in Welsh without having to ask for it. Page 1

4 1. Well-being Summary People are happy, healthy, safe and their rights are protected. They are able to say what they think about the service they receive and what they want from their lives. Our findings People are encouraged to speak out and express themselves as individuals. Systems are in place which encourage and support people to express their views, opinions and preferences. Residents meetings were being held which showed that people were able to raise issues that were important to them. Resident forums chaired by an independent advocate had started taking place. People have access to an independent advocacy service and regular visits are made to the homes. Information about advocacy and complaints were available in easy read formats. Staff talked with us about how they supported people to make choices and decisions about their lives. Person centred plans (PCP) were individual with their likes and dislikes clearly recorded. Reviews were also taking place which look at what s working and what s not working. There was detailed information for staff about how to communicate with people. People are able to express their own views and opinions about the service they receive. People are safe and protected from abuse. There is a clear system in place for recording and reporting all incidents, accidents, concerns and complaints. A sample of these showed appropriate actions had or were being taken. We have received notifications of incidents in a timely manner and referrals were also being made by the management to the local social services department. All staff had received training in Protection of Vulnerable Adults (POVA). Staff had a general understanding of whistleblowing and data protection and there were policies regarding these. Polices and procedures should be reviewed and improved to ensure that staff understand their roles and responsibilities. People feel safe and are protected from avoidable harm, neglect and exploitation. Page 2

5 2. Care and Support Summary People get the help they need, when they need it, in the way they want it. Our findings People receive proactive and responsive care and support. Staff were receiving training in Positive Behavioural Support (PBS) and the Management of Actual or Potential Aggression (MAPA). This enables the staff team to respond to peoples behaviours positively and appropriately. PBS plans were colour coded so that staff could identify and provide the right support to the right person at the right time at an early stage. Practice meetings are being held with staff to review how the PBS plans were working and adapt them to improve the support offered to people. There is a medication policy as well as local operating policies for medication which are specific to each of the homes. A report had been produced which identified that medications errors had occurred. It evidenced the actions that had been taken to try and put this right. Advice and input had been sought from the local health board, GP and local pharmacy to make the necessary improvements. The local health board are due to return to carry out an audit once the new system has been fully implemented. Staff were receiving accredited medication training from an external pharmacy. We saw that people had health action plans; annual health checks and visits to or from the dentist, chiropodist and opticians. Staff team meetings were being held and had improved communication and consistency of the support people received. People are supported to access the relevant community services and get advice from health professionals to ensure their physical and emotional needs are met. Page 3

6 3. Environment Summary People living in Ash are experiencing a more homely place to live as investment is being made to improve this home as well as other people s homes in Highfield A. Our findings People living in Ash are being cared for in a safer, well maintained home and have access to a pleasant outdoor space. Ash is more homely and personalised. There is a mural of a city scene in one of the lounges and a forest and waterfall scene in the hallway. We saw wall stencils were also being introduced gradually at a pace people could cope with. People were being involved in choosing what colours to paint walls and what soft furnishings they wanted. Both lounges and dinning room had curtains in which we were told people had picked from a magazine. New tables and chairs had also been purchased for the dining room. The activity room had been finished which was brightly coloured and provided a place for people to use to go on the computer, do arts and crafts, play games or watch DVD s. People s own rooms were basic and staff informed us individuals like to have changes gradually introduced. We were told that each person s bedroom is assessed in relation to their needs and preferences as part of their initial assessment and this is reviewed. Overtime staff will try to introduce new items into people s rooms as part of their person centred plans. Window coverings were now in place in people s bedrooms providing a more suitable night time environment. The maintenance log recorded work which had been actioned and completed in a timely manner. The manager informed us they were considering ways in which the home could better meet the needs of people with autism. Requests have been made for acoustic wall panelling to further reduce noise levels for people who may have heightened sensitivity to sound. There was now a pleasant garden space which had been made for people to access easily. There were picnic benches and a trellis screen to section it off. There were flower boxes which people were helping to plant and water. We have received written confirmation that the future of three homes known as Beech, Ivy and Hillside are under review. Beech is currently vacant and plans have already started to move people from Hillside and Ivy into more suitable accommodations so the current environments can be reviewed and improved. People are benefitting from the changes to, and plans for, their homes which reflects their individual needs, makes them feel valued and maximises their independence. Page 4

7 4. Leadership and Management Summary The service is being well led. People are listened to and protected by systems that are in place. There is a commitment to raising standards and improving the service people receive. Our findings The vision, values and purpose of the service are clear and being actively implemented. There is a commitment to and evidence of, an improving service. The overall management structure for the company had improved. We have received an application from an individual to become the registered manager for the homes in Highfield A. Staff said morale was good and they felt supported by managers. We were told that the first annual managers meeting had been held to share practice and learn from experiences. The Statement of Purpose and Service User Guide included all the necessary information, setting out what the service was, who it was for and what it could provide for people. Information was provided in English. Consideration needs to be given to how people are being actively provided with a service in Welsh without having to ask for it. The action plan given to us before the inspection visit had been completed. There were a number of quality assurance systems in place and people, relatives and other interested parties were being asked for their feedback about the service. There is an easy read report about the quality of care which is due to be done again in December A social worker is employed by the provider and gives support to family and friends by holding meetings and gaining feedback on their thoughts about the service being offered. A copy of their feedback report was shown to us as well as the independent Lay Visitor reports for Highfield A. This service had been established to provide an impartial opinion about the quality of the service. People are receiving a service which is well led, committed to raising standards, improving service delivery and protects people. People are able to raise their concerns or make a complaint about the service they receive. We saw that there is one clear system in place for recording and responding to concerns and complaints. We spoke with staff about their understanding of the procedures for concerns, complaints, whistleblowing and data protection. Staff had a general awareness of what to do. The policies and procedures should be reviewed and improved to ensure they contain enough detail for staff to fully understand their roles and responsibilities. There was easy read information available for people, explaining how to raise concerns or make a complaint. Staff informed us they support people to do so and also independent advocates visit weekly to provide help and support people. People know how and are supported to raise concerns or complaints which are responded to and acted upon. Page 5

8 4. Improvements required and recommended following this inspection 4.1 Areas of non compliance from previous inspections Regulation 13 (2) which requires the registered provider must make arrangements for the recording, handling, safekeeping, safe administration and disposal of medicines received into the home. This is because we carried out a medication audit and identified that practices need to be reviewed and staff aware of guidelines to be followed. The service is non compliant with Regulation 10 (1) which requires the registered provider and registered manager, having regard to the size of the care home, the statement of purpose, and the number and needs of the service users, to carry on or manage the care home with sufficient care, competence and skill. At the previous inspection we issued a non compliance notice to Mental Health Care (Highfield Park) Limited because they did not meet their legal requirements in relation to: Medication (Regulation 13 (2): At this inspection we were satisfied that arrangements are in place for recording, handling, safekeeping, safe administration and disposal of medicines received into the home had been met. We have been informed of medication errors and we could see these had been quickly identified and notified to us and the local safeguarding team. We read a report about these errors and the actions being taken to address this. Evidence was provided to show staff are receiving accredited medication training. Healthcare professionals are being involved to improve systems in place. At the previous inspection we issued a non compliance notice to Mental Health Care (Highfield Park) Limited because they did not meet their legal requirements in relation to: Carrying on and managing the care home (Regulation 10 (1): At this inspection we were satisfied this Regulation had been met. The management structure has improved. We have received an application from an individual to become the registered manager for this Page 6

9 The service is not compliant with Regulation 25 (2) which requires that the registered person establishes and maintains a system for reviewing at appropriate intervals and improving the quality of care provided at the care home and supplies CSSIW with a report in respect of any review conducted. The service is non compliant with Regulation 4 (1) (c) which requires the registered person a written statement of purpose which shall consist of a statement as to the matters listed in Schedule 1. Regulation 5 (1) which requires the registered person to produce a written service users guide for the care home. service. We were told by staff that morale had improved and they felt supported. We evidenced that the action plan provided to us prior to the inspection visit had been followed. At the previous inspection we issued a non compliance notice to Mental Health Care (Highfield Park) Limited because they did not meet their legal requirements in relation to: Quality of care (Regulation 25 (2): At this inspection we were satisfied this Regulation had been met. We were informed and saw that there were a number of quality assurance systems in place. We did see that people and stakeholders are being asked for their feedback about the service. We discussed the report that had been compiled. At the previous inspection we issued a non compliance notice to Mental Health Care (Highfield Park) Limited because they did not meet their legal requirements in relation to: Statement of Purpose (Regulation 4 (1) (c): At this inspection we were satisfied this Regulation had been met. The Statement of Purpose we were given included all the information required by the Regulation. At the previous inspection we issued a non compliance notice to Mental Health Care (Highfield Park) Limited because they did not meet their legal requirements in relation to the: Service User Guide (Regulation 5 (1) ) Page 7

10 Regulation 24 (2) (b) (d) which requires the registered provider shall, having regard to the number and needs of service users, ensure that the premises to be used as the care home are of sound construction and kept in a good state of repair. Regulation 23 (1) The registered person shall prepare and follow a written procedure for considering complaints made to the registered person by a service user or person acting on the service users behalf. At this inspection we were satisfied the Service User Guide we were given had all the information required by the Regulation. It is easy to read and understand because it was plain English and had graphics and or photographs to help people understand it. At the previous inspection we issued a non compliance notice to Mental Health Care (Highfield Park) Limited because they did not meet their legal requirements in relation to: Premises (Regulation 24 (2) (b) (d): At this inspection we were satisfied this Regulation was being met. Further work had been carried out to the home we visited which was more homely and well maintained. There are plans in place to review three of the other homes to ensure that people are living suitable homes which meet their needs. At the previous inspection we issued a non compliance notice to Mental Health Care (Highfield Park) Limited because they did not meet their legal requirements in relation to: Complaints (Regulation 23 (1): At this inspection we were satisfied this Regulation had been met. There is now one clear system in place for the recording and reporting of concerns and complaints. Page 8

11 4.2 Areas of non compliance identified at this inspection No areas of non compliance were identified at this inspection. 4.3 Recommendations for improvement We recommend the following: The service should review and improve its policies and procedures so staff fully understand their roles and responsibilities. Providing a service in Welsh without people having to ask for it will help to ensure people receive a quality service which is able to meet their needs. Page 9

12 5. How we undertook this inspection This was a focussed inspection to check on the non compliance notices issued at the previous inspections: September 2015, April and May We made an unannounced visit to Ash which is one of the homes in Highfield A. This was on the 11 th October 2016 between 9:30 a.m. and 4 p.m. Two inspectors visited the home. The following methods were used: We spoke with one person living in the home during the day, three members of staff and the manager. We sent questionnaires to people living in the home, staff relatives and professionals. We received one back from a staff member. We looked at a wide range of records: we focused on polices and procedures, information about medication, two care plans, activities, staff training record, quality assurance report, Statement of Purpose, Service User Guide, concerns, complaints, accident and incident reports and information about plans to improve environments. We did not use the Short Observational Framework for Inspection (SOFI2) during this inspection. This is because we were able to speak directly with the person who was there on the day we visited the home. We provided feedback during our inspection visits and also gave formal feedback on the 26 th October Further information about what we do can be found on our website Page 10

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14 About the service Type of care provided Registered Person Registered Manager(s) Adult Care Home Younger Mental Health Care (Highfield Park) Ltd No registered manager Registered maximum number of places 20 Date of previous CSSIW inspection 28 April, 29 April and 9 May 2016 Dates of this Inspection visit(s) 11/10/2016 Operating Language of the service Does this service provide the Welsh Language active offer? English The service does not provide the active offer in relation to the Welsh language. Additional Information: An application has been submitted to CSSIW by the manager to become the registered manager for this service.

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