Inspection on 05/01/07 for 18 Leafdown Close

This inspection was carried out on 5th January 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 found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

18 Leafdown Close 28/11/07

18 Leafdown Close 07/02/06

18 Leafdown Close 30/09/05

18 Leafdown Close 01/02/05

18 Leafdown Close 06/09/04

18 Leafdown Close 17/02/04

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Polesworth Group Pooley Heights

Polesworth Group 32 Station Road

Polesworth Group 70 Long Street

Breme

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Polesworth Group 68 Long Street

10 Whitfield Avenue

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 18 Leafdown Close Hednesford Cannock Staffordshire WS12 2NJ Lead Inspector Dawn Dillion Key Unannounced Inspection 5 January 2007 15:30 18 Leafdown Close DS0000005089.V328043.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 18 Leafdown Close DS0000005089.V328043.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. 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 18 Leafdown Close Address Hednesford Cannock Staffordshire WS12 2NJ 01543 425637 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) Mrs Valerie Bullman Mrs Valerie Bullman Care Home 1 Category(ies) of Learning disability (1) registration, with number of places 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7 February 2006 Brief Description of the Service: Leafdown Close is a residential home located in Hednesford, Staffordshire; the home is registered to provide a service for one adult, category of registration learning disability. The two-storey semi detached property comprises of a lounge, leading to a dining area and a fitted kitchen. On the first floor level there are three single occupancy bedrooms and a bathroom that is equipped with a toilet, washbasin and a shower. There is a well-maintained garden at the rear of the property, adequate car parking facility is provided at the front of the premises. Leafdown Close provides a warm and welcoming atmosphere with a positive emphasis focused on normalisation, providing the necessary support and assistance to ensure that the service user has access to leisure facilities and to have a valued role within her local community. All healthcare services are accessible to the service user to ensure and maintain all healthcare needs. The Registered Manager provided support and supervision on a daily basis to meet the assessed needs of the service user. The fees chargeable for the service and provisions provided at Leafdown Close is £397.00p per week. 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The unannounced key inspection of Leafdown Close was undertaken within three hours. The inspection methodologies that were used, to establish the quality of care provided and the effectiveness of the management of the home, to promote quality, diversity and best practices, entailed the examination of records relating to the homes policies and procedures. A tour of the property was also undertaken to ensure that the environment and systems in operation were safe and suitable to meet the needs of the service user. An informal interview was undertaken with the service user to obtain her views and opinion with regards the service provided at the home and to also establish her experience, in relation to the support, supervision and guidance provided to promote social inclusion and suitable social activities. What the service does well: What has improved since the last inspection? Discussions with the service user confirmed that she had obtained another voluntary work placement since the last inspection visit. 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 6 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. 18 Leafdown Close DS0000005089.V328043.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 18 Leafdown Close DS0000005089.V328043.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service and discussions with the Registered Manager. The homes admission procedure ensured that any prospective service user would be provided with sufficient information, to enable them to have a choice. EVIDENCE: The homes Statement of Purpose provided information relating to the current service and provisions available. Leafdown Close is registered to provide a service for one service user, who had been in residence for a number of years. Discussions with the Registered Manager, confirmed that any future prospective service user would be subject to a pre admission assessment prior to admission; to establish the homes suitability to meet the individuals assessed care and social needs. 18 Leafdown Close DS0000005089.V328043.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 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The examination of the care plan, risk assessment and discussions with both the service user and the Registered Manager. The model of service promoted service user involvement to ensure that the individual’s needs were met appropriately and encouraged independence and normal daily living. EVIDENCE: The examination of the care plan, risk assessment and discussions with the service user, confirmed that she was actively involved in the development of her care plan and subsequent reviews. There was a very positive emphasis focused on empowering the service user to make major decisions as well as everyday choices with regards to her lifestyle. 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 10 The care plan provided information relating to the service users goals and aspiration and also identified the level of support and guidance required to enable her to achieve. The care plan was reviewed on a regular basis to reflect the changing needs of the service user and also identified the goals achieved. There was no evidence of any restrictions imposed within the home but a risk assessment was implemented, to identify the support required, to ensure that the service user was able to take a controlled risk, within and outside of the home, to live a normal and independent lifestyle. Discussions with the service user confirmed that she was able to make decisions relating to her lifestyle. The service user attended day care services three days a week and had access to a self-advocate, if and when required via this route. The service user required some element of support with her financial affairs, discussions with the service user and the examination of records identified, that she was provided with the necessary support, to enable her to have control over her finances and also to be protected from financial abuse. 18 Leafdown Close DS0000005089.V328043.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, 14, 15, 16 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The examination of the care plan, discussions with both the service user and the Registered Manager, information obtained from the service user comment card and general observations during the process of the inspection. The service provided at Leafdown Close was flexible and promoted diversity and equality, to ensure that the service user had a range of opportunities to promote personal development and to have a positive presence within the community. EVIDENCE: The service user informed the Inspector that she had recently obtained a paid work placement at Burntwood Railway Café one morning a week and continued to work at her previous voluntary placement within a kitchen on Wednesdays 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 12 and attended day care services for the remaining three days. The service user confirmed that she was involved in various activities at the day care centre of which entailed cooking, drama, social activities and a one to one session with her key worker. The service user also informed the Inspector that she was a member of a dance club and that she had taken an active part in the Christmas performance. The service user also had access to the local college to learn new skills via the day care service. The model of service at Leafdown Close ensured that the service user was provided with the necessary support and assistance to access leisure services and to have a positive presence within her local community. Discussions with the service user confirmed that she was actively involved in decisions relating to any holidays and short breaks throughout the year, the service user informed the Inspector that arrangements were in place to go to a pantomime, a visit to Italy, London and Blackpool. The service user informed the Inspector that she attended church on a Sunday and was excited in becoming of fully pledged member of the church. The service user confirmed that she was able to maintain contact with her family and friends and that she occasionally visited her sister. The daily routine within the home was observed to be relaxed, with the service user having freedom of movement throughout and access to all facilities within the home. On the day of the inspection the service user had attended the day care centre, on her arrival to Leafdown Close, she made the Inspector and herself a drink and opened her mail that had been delivered that morning. She informed the Inspector of the events of the day and expressed to the Inspector that she was happy living at Leafdown Close. Meals were provided to reflect the likes and dislikes of the service user and in conjunction with the meals provided at the day care centre. The service user informed the Inspector that she was involved in the purchase of food provisions and confirmed that the Registered Manager was a good cook. On the day of the inspection the Registered Manager was preparing a lamb stew, using all fresh produce. The service user did not have any special dietary requirements with regards to cultural, religion or health. 18 Leafdown Close DS0000005089.V328043.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 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The examination of records, discussions with the service user and the Registered Manager. The home practices and procedures ensured that the service user had access to relevant healthcare services for routine screening. EVIDENCE: The service user was very independent and required very minimal support with personal care. As previously identified within the contents of this report the service provided at Leafdown Close was flexible to meet the needs of the service user. Discussions with the service user identified that she did have a routines with her daily activities and tasks and had a preference to retire to bed early. The service user was mobile and there were no requirements for moving and handling, specialist aids or adaptations. 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 14 Discussions with the service user confirmed that she had access to relevant healthcare services for routine health screening. The service user informed the Inspector of all health visits within the past 12 months. With reference to the homes medication system, the service user self administered her medicines and maintained a signed record of when she had taken her medicines. The service user confirmed that she had seen her General Practitioner to have her medication reviewed. 18 Leafdown Close DS0000005089.V328043.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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The examination of the homes complaint procedure and discussions with the service user. The homes practices and procedures ensured that the service user was protected from any form of abuse. EVIDENCE: There was a complaints policy in place that was accessible to the service user; providing information relating to the Commission For Social Care Inspection and contact details for Social Services. The Commission For Social Care Inspection has not received any complaints relating to the home in recent years. The service user had access to a self-advocate at the day centre and would also be able share any concerns with her key worker. The service user also informed the Inspector that she was very happy at Leafdown and that the Registered Manager was “OK.” There had been no new staff recruitment in recent years; previous examination of staff files confirmed the undertaking of a Criminal Record Bureau check. 18 Leafdown Close DS0000005089.V328043.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 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service of which involved the inspection of the premises. The layout and the design of the property were suitable to meet the needs of the service user. EVIDENCE: 18 Leafdown Close is located in Hednesford, Staffordshire and is accessible via public transport. The semi-detached property was in keeping with the local community and provided three single occupancy bedrooms (registered to provide residential care for one). En suite facility was not provided; the bathroom was located in close proximity to the bedroom. 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 17 The bathroom was situated on the first floor, equipped with a bath, toilet, washbasin and shower. On the ground floor there was a lounge area, which provided a comfortable area for relaxation. Leading from this area was a separate dinning room. There was an attractive fitted kitchen in place. The garden at the rear of the property was well maintained. Adequate parking facility was provided at the front of the property. The general cleanliness and hygiene of the home was of a very high standard. Smoke detectors were installed throughout the home and records confirmed that fire-fighting equipment were serviced on a regular basis. The service user showed the Inspector around her bedroom, the bedroom was tastefully decorated and was equipped with essential furnishings and items to provide a comfortable area; the service user informed the Inspector that she was happy with her bedroom. Adequate heating, ventilation and natural lighting were provided throughout the home. Leafdown is a normal domestic dwelling and there were no specific systems in place with regards to infection control and there were no issues relating to the management of bodily fluids. As previously identified the cleanliness and hygiene within the home was of a very high standard. The service user did not have any physical or sensory impairment hence, there were no specialist systems or adaptations required, past discussions with the Registered Manager confirmed that if and when necessary, every effort would be made to provide the necessary adaptation to meet the needs of the service user. The examination of the fire risk assessment identified, that it was last reviewed on 04/11/05, the Registered Manager should ensure that this is reviewed and also incorporates additional information relating to the new fire regulations and to have an evacuation plan. 18 Leafdown Close DS0000005089.V328043.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 and 34 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Discussions with the service user and the Registered Manager. The service user was provided with the necessary level of support to live a lifestyle of her choice. EVIDENCE: Leafdown Close was a normal domestic dwelling; there were no staffing or management structure. The Registered Manager was experienced within social care and was proactive in providing a diverse service to promote the independence, right and choice of the service user. Care, support and guidance was provided by the Registered Manager, one staff member that was also a friend of the family was currently employed on a casual basis, to provide additional support if and when required. 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 19 General discussions with the Registered Manager confirmed that the casual staff was very occasionally used due to the service user’s improved skills and independence over the years. The previous inspection report identified a requirement; in relation to the Registered Manager undertaking further training in first aid, this requirement remains outstanding. 18 Leafdown Close DS0000005089.V328043.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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The examination of fire safety records, risk assessments, discussions with the Registered Manager and general observations. There was a positive emphasis focused on diversity and equality, promoting the rights and choice of the service user to ensure that the individual lived a fulfilled lifestyle. EVIDENCE: There was a positive commitment in providing a flexible and diverse service to promote normal daily living and the independence of the service user. As previously identified within the contents of this report, the Registered Manager was experienced within social care and had obtained the National 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 21 Vocational Qualification, level 2 in care. Discussions with the Registered Manager, identified that she had a sound knowledge of the care needs of the service user and was very proactive in empowering the service user to live a lifestyle of her choice and was currently assisting the service user to find paid employment. With reference to the quality assurance, the home distributed a questionnaire to the service user and other agencies that are involved with the service user, such as the Social Worker and the Key Worker at the day care centre. The examination of these questionnaires identified that the last time they distributed was in November 2005. It has been identified as a recommendation within the contents of this report that consideration should be given in reviewing the questionnaire to reflect the current service and to distribute them again. The examination of records and systems with regards to the health, safety and welfare of the service user identified, that there was a current certificate of maintenance in place with reference to fire safety. The environment was safe and conducive in meeting the needs of the service user. 18 Leafdown Close DS0000005089.V328043.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 2 25 X 26 X 27 X 28 X 29 X 30 4 STAFFING Standard No Score 31 X 32 2 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 4 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 4 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 23 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 YA32 Regulation 18 Requirement Training relating to fire awareness and first aid should be undertaken by the Registered Manager. (Outstanding from 01/06/06) Timescale for action 01/04/07 2 YA24 23(4)(a)(c)(iii) To ensure that the fire risk assessment is reviewed and incorporate an evacuation plan. 01/04/07 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 YA39 Good Practice Recommendations To ensure that the quality assurance questionnaire reflects the current service provided and to distribute the questionnaires to the appropriate agencies. 18 Leafdown Close DS0000005089.V328043.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Stafford Office Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 18 Leafdown Close DS0000005089.V328043.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!