Inspection on 01/02/06 for 484 Halifax Road

This inspection was carried out on 1st February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

484 Halifax Road 01/06/09

484 Halifax Road 05/12/08

484 Halifax Road 06/12/06

484 Halifax Road 22/02/05

484 Halifax Road 27/10/04

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

CARE HOME ADULTS 18-65 484 Halifax Road Bradford West Yorkshire BD6 2LH Lead Inspector Carol Haj-Najafi Unannounced Inspection 1st February 2006 09:30 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service 484 Halifax Road Address Bradford West Yorkshire BD6 2LH 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) 01274 676466 01274 676466 Brunel & Family Housing Association Limited Care Home 6 Category(ies) of Learning disability (6) registration, with number of places 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2005 Brief Description of the Service: Halifax Road is a Brunel Support Works home situated on the outskirts of Bradford. The home is registered to provide long term personal and nursing care for up to 6 adults with learning disabilities. Staff are employed by Bradford District Care Trust.The building is a large three storey terraced house. Accommodation is provided on two floors, there are 6 single bedrooms. There are three bath/shower rooms and a domestic style kitchen. All laundering is undertaken on the premises. Halifax Road has a garden at the front of the house and a car parking area to the rear of the building. Local shops and bus routes are within easy access. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection between 09.30am and 3.30pm. The purpose of the inspection was to make sure the home was operating and being managed to a satisfactory standard. I spoke to staff, the temporary manager and the head of adult services for Brunel Housing Association. Service users living at the home have complex needs and discussions with service users were limited. The inspector observed interaction between service users and staff. Records were inspected including care plans, assessments and staff records. The manager is covering on a temporary basis until a new manager starts at the beginning of April. Feedback was given to the manager at the end of the inspection. What the service does well: What has improved since the last inspection? Communication has improved and staff said new management arrangements are working well. The morning routine for one service user has changed and it is now more flexible and relaxed. This is good because it has given the service user more control. Environmental changes have made a big improvement for service users. The location of communal rooms has changed and now service users are accessing communal rooms more. Staff have attended training with the local authority adult protection unit. This has given staff a better understanding of adult protection. Financial systems have improved. Service users monies are no longer pooled. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 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. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3 & 4 A recent admission was not carried out satisfactorily although part of the reason for this was the need to find a placement within a short period of time. The service user has settled in well. Assessments and care plans should have been updated. EVIDENCE: There had only been one admission within the last twelve months, and the manager explained that because of the circumstances of the admission this had been completed much more speedily than it would have been for a routine admission. The service user had been living at the home for six weeks and staff and the manager said they had settled in well. A formal assessment had not been carried out before the admission had taken place. The manager said the service user had visited the home on three occasions before admission but only one of these visits had been recorded and the record for this visit only referred to an incident that had occurred. A lot of background information, care plans and risk assessments were available from the placement where the service user had previously lived but most of this was between one and four years old. No new care plans or assessments had been completed whilst the service user had been living at Halifax Road. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 9 Brunel has an admission policy but staff were not aware of this, and an admission policy had not been followed on this occasion. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 There is a lot of information about how a service user’s needs should be met but the care plans need organising so the information can be more easily accessed. The care plans need to be used as working documents so staff are clear about how a service user’s needs should be met. Changes to the morning routine for one service user are good. EVIDENCE: Three care plans were looked at and all of them had good information about each service user’s needs. There was a lot of information in each file and it was difficult to find current information. The review dates for most of the plans had passed. The staff team do not use the care plans on a regular basis. Staff talked about how they assess risk and ensure service users have an opportunity to develop skills. Making hot drinks was an example where risk is individually assessed. Each service user has a range of risk assessments in their file. Staff said service users are encouraged to make decisions about outings, what to wear and bedtimes. Staff and the manager talked about a recent change that has been introduced which has given one service user more flexibility on a 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 11 morning. The previous routine had been very rigid, where as the new routine gave the service user more control. This was a positive change for the service user. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16 & 17 Service users have opportunities to go on regular trips out and are encouraged to develop different skills. Activities in the home could improve. The quality and variation of meals should also improve and a system for monitoring them must be introduced. EVIDENCE: All service users are encouraged to help around the home. This includes dusting, vacuuming, washing up, emptying bins, making beds and cleaning bedrooms. The home has a fish tank. One service user enjoys feeding the fish and the birds in the garden. Staff said that supporting service users to develop independent living skills was something the home does well. Staff said generally the home had become more relaxed which has had a positive affect on service users and staff. Service users attend various day care services although some are currently receiving a reduced service because their day centre is being refurbished. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 13 There are regular trips out on the minibus, and recently some service users have gone out walking. Service users enjoy watching television and spending time with staff but other activities in the home are limited. Staff and the manager agreed this is an area that should be developed. Service users are supported to maintain contact with relatives. Where possible family are involved in making decisions and reviewing care needs. An increase in the weekly food budget has recently been agreed with management from Brunel. The home does not have a fixed menu but meals are decided on a daily basis. A record of food served should be completed every day to enable nutritional content and variation to be monitored. Entries in the food record were irregular. Some meals were evidently nutritious but there was also evidence that convenience food was regularly provided. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users health care needs are met. Medication systems are well organised. EVIDENCE: Staff talked about individuality and gave examples of how personal support is provided in different ways to suit the preferences of individual service users. A recent change to one service user’s morning routine (which was also used as an example in the individual needs and choice section) is now set around what works best for the service user. Up until recently this was not the case. Systems are in place to monitor health care needs. The home works closely with health care professionals. All service users attend Waddiloves’ health centre for dental and podiatry appointments. Service users are weighed but this is not done regularly. Medication storage and records were looked at. Medication administration records were correctly completed and storage of medicines was tidy and well organised. The manager is changing storage facilities for daily medication to make it more accessible for staff. A suitable cupboard has been identified. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are safeguarded from abuse. EVIDENCE: The last inspection identified that some financial systems needed changing to make sure that service user’s monies were properly accounted for. These changes have been carried out although one service user was still receiving less than the recommended minimum personal allowance. This must be looked at. The last inspection also identified that staff and management should receive appropriate adult protection training. The manager confirmed that staff had attended training with the local authority adult protection unit. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 & 30 The changes in the communal areas are good. Some parts of the home are looking shabby and it will benefit from the money that has been allocated for refurbishment. EVIDENCE: Since the last inspection, there have been some changes to the environment. A ground floor bedroom has been relocated to the first floor and the lounge in now on the ground floor. One communal room is now allocated as a dining room, and service users have more space at meal times. All staff said the changes were very positive and service users were using the communal rooms more. The last two inspections identified that some areas of the home were dirty, a deep cleaning contract was set up to address this but this has not been carried out as agreed. The manager said Brunel has been chasing this up. The last inspection also identified that the washing machine does not have a suitable sluicing/disinfecting facility to wash soiled laundry. A new machine with an appropriate programme was due to be delivered four days after this inspection. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 17 Some work is still required to meet the recommendations from the last fire officer’s visit. The manager from Brunel anticipates this would be completed by the end of April. Although the home looks reasonably well organised, some areas of the home are looking shabby. The stair carpet is worn. The manager from Brunel confirmed that money has been allocated to decorate and carpet the hallway and bedrooms. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32 & 34 Service users benefits when three members of staff are on duty. These staffing levels should be provided on a permanent basis. Information that is obtained during recruitment is not available therefore it is not possible to confirm the home conducts a thorough recruitment process. EVIDENCE: Staffing at the home has been increased. Two waking night staff are on duty rather than one waking staff and one sleep in staff. During the day there has also been occasions when three staff have been on duty rather than two. A student nurse has also been there on placement. The manager and staff said there is a big difference in the quality of service that is provided when three staff are on duty. Service users have more opportunities to go out in smaller groups and it is possible to do more individual work. A staffing proposal has been sent to Bradford District Care Trust for consideration. The manager said staff information which is obtained as part of the recruitment process is not kept in the home. She agreed to contact Human Resources, who hold the relevant information and obtain copies. This is an outstanding requirement from the last inspection. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 The temporary manager has successfully introduced some good changes which have benefited service users. The home needs a permanent manager to continue the good work. Service user meetings should be introduced. EVIDENCE: The home does not have a registered manager in post. A temporary manager has worked at the home since October 2005. A new manager is starting in April, and the manager from Brunel said an application would be submitted to the CSCI. The temporary manager has been instrumental in making positive changes during her short time at Halifax Road. Staff said the service had benefited from having good communication, clear responsibilities and support to carry out delegated tasks. The last two inspections recommended for service user meetings to be introduced; this has still not taken place. There are no formal service user 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 20 surveys or service user meetings. Previously it has been agreed that service users would benefit from having additional opportunities to express their views. An electrical wiring certificate was not available at the last inspection. An electrical wiring test was carried out in August 05 but a certificate was not issued because remedial work was required. This work has not yet been carried out but the manager from Brunel said this would be completed alongside the fire safety work before the end of April. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 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 1 3 3 4 2 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 3 29 X 30 2 STAFFING Standard No Score 31 X 32 2 33 X 34 2 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 2 X 2 X X 2 X 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 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 YA2 Regulation 14 Requirement The registered person must make sure service user’s needs are assessed before they are admitted to the home. The registered person must ensure care plans are reviewed regularly. The plans should be organised so they can become effective working documents. The registered person must ensure service users have a nutritious and varied diet. The registered provider must ensure the home meets the outstanding recommendations of the fire authority. (Timescale of 31/12/05 not met) The registered provider must make sure the home is reasonably decorated and the stair carpet must be replaced. The registered provider must ensure the washing machine has an appropriate programme to control the risk of infection. (Timescale of 30/09/05 not met) The registered person must review the staffing levels to ensure service users’ needs are met. DS0000019914.V279936.R01.S.doc Timescale for action 28/02/06 2 YA6 15 30/04/06 3 4 YA17 YA24 16 16 31/03/06 30/04/06 5 YA24 23, 16 30/04/06 6 YA30 13 28/02/06 7 YA32 18 30/04/06 484 Halifax Road Version 5.1 Page 23 8 YA34 19 9 YA37 8 10 YA37 23 The registered person must 30/04/06 ensure any gaps in employment are explored, and make available for inspection all recruitment documentation. (Timescale of 31/08/06 not met) The registered person must 30/04/06 make sure the home has appropriate long term management arrangements. This must include an application for the manager to be registered with the CSCI. The registered person must 30/04/06 ensure the home’s electrical wiring meets the required standard. 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 6 Refer to Standard YA4 YA14 YA19 YA23 YA32 YA39 Good Practice Recommendations The registered person should make sure service users have sufficient opportunities to visit the home before admission. The registered person should improve the range of leisure activities. The registered person should make sure service users’ weight is monitored. The registered person should ensure service users receive their full personal allowance. The registered person should ensure 50 of care staff in the home achieve a care NVQ 2. The registered person should look at how systems can be developed to obtain service user views. 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 484 Halifax Road DS0000019914.V279936.R01.S.doc Version 5.1 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. 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