Inspection on 13/11/07 for Southlees

This is the latest available inspection report for this service, carried out on 13th November 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Southlees 07/03/06

Southlees 08/11/05

Southlees 08/02/05

Southlees 24/05/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Southlees 84 Aldonley Almondbury Huddersfield West Yorkshire HD5 8SS Lead Inspector Helen Battle Key Unannounced Inspection 13th November 2007 03:00 Southlees DS0000026328.V354873.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 Southlees DS0000026328.V354873.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. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlees Address 84 Aldonley Almondbury Huddersfield West Yorkshire HD5 8SS 01484 428366 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) lmacdonald@bridgewoodtrust.co.uk Bridgewood Trust Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th February 2007 Brief Description of the Service: Southlees is a care home providing personal care and accommodation for six adults with learning disabilities. It is owned by the Bridgewood Trust, a voluntary organisation providing a range of services to adults with learning disabilities. The home is situated on a housing estate in the Almondbury area of Huddersfield, with a local shop and pub within walking distance of the home. There is a wider range of shops and community facilities within 5 minutes’ drive of the home. The home is close to a bus route. The property is a detached house in keeping with other local houses. Accommodation is on two floors. People have their own bedrooms. In addition to this, people share a spacious lounge, dining room, kitchen, two bathrooms, two toilets and a utility room. There is a parking area and small garden to the front of the property and a large garden to the rear. French windows leading from the dining room into the back garden on to a patio area have recently been added to the accommodation. The provider informed the Commission for Social Care Inspection on 6 September 2007 that the fees range from £316.17 - £723.66. Items not covered by fees include toiletries, outings and holidays. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection, a visit to the home took place. The inspector, Helen Battle, visited the home unannounced from 3 pm to 6.30 pm. Whilst at the home, key documents such as care assessments, care plans, daily records and staff records were looked at, and so was the accommodation. One member of staff was spoken with along with the acting manager. Five people living at the home were spoken with. The manager had been asked to complete a questionnaire with information about the service, the people who live at Southlees and the staff working at the home. This was returned to the Commission prior to the visit taking place. A self assessment was also undertaken by Bridgewood Trust to help them and CSCI judge the quality of the service being provided. Surveys were sent to all six people living at the home, their families and GPs. Four surveys were returned from people living in the home, and five were returned from relatives. These were positive. Comments included: “They make my relative feel at home; that she belongs.” “I am very satisfied with the care that my relative receives at Southlees, she is very happy there.” “My relative is well cared for and I am more than happy with the standard of care she receives and the working practice of carers.” The inspector would like to thank the people living in the home and the staff for their warm welcome, co-operation and hospitality during the visit. What the service does well: People are properly assessed and consulted prior to moving into the home. People’s needs are set out in a clear plan of care to ensure that staff know how to meet people’s needs in a consistent way. People are supported to participate in appropriate activities and are supported to maintain contact with families and friends. Staff receive training appropriate to their work. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Southlees DS0000026328.V354873.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 Southlees DS0000026328.V354873.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. We have made this judgment using a range of evidence, including a visit to this service. People are properly assessed before moving into the home with the assurance that their needs will be met. EVIDENCE: The care records of two people living in the home were examined and all were found to have appropriate community care assessments, which are carried out by Social Services prior to admission, and provided the information the home needed about these people. There was clear evidence in the records that people are consulted about moving in and are given the opportunity to visit the home on a number of occasions to meet staff and the other people who live in the home. Southlees DS0000026328.V354873.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. We have made this judgment using a range of evidence, including a visit to this service. Plans of care are in place which reflect the current needs of the people living in the home. People make decisions about their lives and take risks as part of a more independent lifestyle where possible. EVIDENCE: The care plans of two people living at the home were examined. These were well detailed and reflected the current needs of the individuals. Work has been carried out to update and improve the care records and this is seen as a positive development in meeting people’s needs consistently. There was good evidence in care records of the involvement of families in the lives of people and good detail about people being supported in making their own decisions about their lives. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 10 Entries in the daily records were of a good standard and gave a good account of how people are and how they have spent their day. There was also excellent detail in the records of a person who had been ill and demonstrated the person had received the required intensive input from staff. Two people living at the home were spoken with and generally were satisfied with the care and support provided. Both stated that the staff are very good to them and that they get on well. Responses from surveys indicated that relatives, health professionals and people living in the home are all very satisfied with the service provided. The support given by the staff working at the home to enable people to make choices and take risks was good. This was evident on the day of the visit in observing staff interaction and activities with people living in the home. People living in the home stated that they were given choices and consulted about life in the home. Southlees DS0000026328.V354873.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. We have made this judgment using a range of evidence, including a visit to this service. People living in the home take part in appropriate activities and are part of the local community. Appropriate relationships are maintained and people’s rights and responsibilities are respected. Meals provided at the home are of a good standard. EVIDENCE: People living at the home take part in a variety of activities and attend day centres suitable for their needs. These include day centres, going out to do their own shopping, going to local groups and clubs. The people living in the home chose to go on holiday to Scarborough this year and evidently enjoyed their week away. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 12 People living in the home are supported to go to local hairdressers, GPs, optician and chiropody appointments. On the day of this visit, three people had been out to Cawthorne Park for the day and two others had been to “Craft” at a day centre run by Bridgewood Trust. During the evening of this visit, two people had previously planned to go to a keep fit class but chose not to go this week. Two people were planning to go to the supermarket later in the evening. People were seen to be treated with respect and their privacy and dignity maintained by staff during this visit. People living in the home are supported to maintain links and relationships with friends and family where possible. People said that they are allowed to see visitors at any time and the home has evidently worked hard with people to support them with maintaining relationships. Three people were reported by the acting manager to go out to a place of worship regularly with their families. Plans are underway for Christmas, and some people are planning to spend the day with their families. Christmas parties are also being arranged. The meals are of a good standard. Feedback from people living in the home, and visitors, was very positive and the meal served on the day of the visit looked appetising. The evening meal was lamb chops, mashed potato, sweetcorn and leeks, followed by rhubarb crumble and custard. Southlees DS0000026328.V354873.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. We have made this judgment using a range of evidence, including a visit to this service. People receive support in a way they prefer and require with their emotional and health needs being met. People living in the home are protected by the home’s policy and procedure for dealing with medication. EVIDENCE: People living in the home indicated in their responses to surveys that the staff are kind and provide personal assistance in a discreet manner, which promotes privacy and dignity. People living in the home stated that they are able to choose what times they get up and go to bed. It was evident that people choose their own clothes, hairstyles and makeup. There was evidence in people’s records that support is also provided from specialist nurses and support from the hospital. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 14 The medication of two people was checked and was found to tally with the records held. Procedures are in place to safeguard people living in the home regarding medication. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 15 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. We have made this judgment using a range of evidence, including a visit to this service. Generally, people feel their views are listened to and acted on. People are protected from abuse, neglect and self-harm. EVIDENCE: People who responded to the surveys felt that they could speak to any member of staff and that they would be listened to. There have been no complaints made to the home since the last inspection. The complaints procedure is available in symbol form for people living in the home. Safeguarding (Adult Protection) training has been given to all staff during the last year. Care needs to be taken to ensure that this is kept up to date. Staff spoken to during the visit demonstrated a good understanding of safeguarding (adult protection) issues and procedures. The senior management of Bridgewood Trust have taken action regarding improving practice in relation to safeguarding issues in recent months. The personal monies of two people were checked and were found to reconcile with the records held. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 16 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. We have made this judgment using a range of evidence, including a visit to this service. The people live in a comfortable and safe environment and the home is clean and hygienic. EVIDENCE: The accommodation at the home is of a good standard. People living in the home have been encouraged to take their own items into the home to personalise their rooms. Since the last inspection, new overhead tracking to assist one of the people living in the home to move more easily has been fitted. The downstairs bathroom has been refurbished and made into a shower room, and the downstairs toilet is also being refurbished. New sofas have bought for the lounge. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 17 Plans are in place to refurbish the upstairs toilet and bathroom, and the kitchen area. Decoration is planned for the hall, stairs and landing. The home is set in nicely maintained gardens. The home was clean during this visit. Any odours at the home are being managed adequately. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 18 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 good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to this service. People are supported by competent and qualified staff, and are protected by the home’s recruitment practices. Staff are receiving mandatory training within recommended timescales. EVIDENCE: All the staff working at the home have received movement and handling, safeguarding (adult protection), health and safety, and fire safety training within the last 12 months. Staff were seen to be supporting people in a competent and professional manner. Staff also complete training regarding supporting people who have a learning disability. The recruitment process at the home protects the people living there. The records for two members of staff were examined. Both of these records were complete. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 19 Staffing levels are provided to meet the needs of the people living in the home. There are always two members of staff on duty at peak times during the day and this is increased when needed to support people to take part in specific activities. There is one member of waking night staff on duty. Staff receive one to one supervision sessions with a manager every two months. Records were seen to support this. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 20 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. We have made this judgment using a range of evidence, including a visit to this service. People benefit from a well run home and their views underpin development at the home. The health, safety and welfare of people is protected. EVIDENCE: There has been a change in the management arrangements at Southlees since the last inspection. The registered manager has taken up post elsewhere and there is an acting manager in place currently. This person has worked for the organisation for a number of years and so there is continuity for the people who live in the home as they all know the acting manager. Interviews have recently taken place for a new manager. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 21 People’s views are listened to and underpin any development of the home’s policies and practices. Monthly management visits are carried out. Quality assurance processes are in place and audits are carried out regularly on medication, care records and the environment. There were no apparent health and safety issues observed during this visit. Weekly tests of the emergency lighting and fire alarm systems are recorded. Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 22 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 Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 X 3 X X 3 x Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 23 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA24 Good Practice Recommendations Southlees DS0000026328.V354873.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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. 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