This inspection was carried out on 5th January 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 no outstanding requirements from the previous inspection report,
but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.
CARE HOME ADULTS 18-65
Alderson Road 12 12 Alderson Road Harrogate North Yorkshire HG2 8AS Lead Inspector
Kate Shackleton Unannounced Inspection 5 January 2006 11:10
th Alderson Road 12 DS0000007877.V275551.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 Alderson Road 12 DS0000007877.V275551.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. Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service Alderson Road 12 Address 12 Alderson Road Harrogate North Yorkshire HG2 8AS 01423 520251 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) Northern Life Care Limited T/A U.B.U. Miss Deborah Shepherd Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Registered for 6 residents with Learning Disabilities some of whom may also have Physical Disabilities 19th May 2005 Date of last inspection Brief Description of the Service: 12 Alderson Road is a large Victorian terrace house situated close to Harrogate town centre. The home provides accommodation and personal care to six adults with a learning disability some of who have a physical disability. The home is owned by UBU formerly Northern Life Care. The house is on three floors. There is no passenger lift. All of the bedrooms are single; one of them has an en-suite facility. Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Some people that live at this home have autism and find visitors to the home upsetting, so the home was told two hours before the inspection was due to start so that staff could prepare people. The inspection took four hours including one hour’s preparation time. Time was spent talking to staff and observing how they support service users. Communication difficulties prevented discussions with service users. Some records were looked at and a tour of the premises was done. What the service does well: What has improved since the last inspection? What they could do better:
There is a written system to check that everything in the home is OK and a record of what needs to be done in the future to improve it. This doesn’t include what service users, their families and other professionals think of the home and it should do. Senior managers need to come up with some ideas as to how this might be achieved. Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 6 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. Alderson Road 12 DS0000007877.V275551.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 Alderson Road 12 DS0000007877.V275551.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 Prospective service users needs are properly assessed to make sure that the service can meet their needs. EVIDENCE: There have been no admissions since the last inspection. All service users are admitted following care management assessment and the homes own pre admission assessment. This includes having meetings with the prospective service user and their family/representative. Visits to the house are arranged before an admission date is agreed. Admission is subject to a probationary period to enable a fuller assessment and to make sure that all the service users who live in the house are happy with the arrangements. Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): None of these standards assessed at this inspection EVIDENCE: Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 10 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): 15 and 17 Service users benefit from maintaining good relationships with family and friends. Dietary needs are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: Service users are encouraged to maintain contact with family where appropriate. Staff support some service users to travel to their family home. Friends can be invited back to the house. Staff often have to advocate on behalf of service users to maintain friendships. A member of staff was seen involving a service user in the preparation of lunch. Menus are arranged around the likes and dislikes of service users with some attention being paid to “ healthy living”. At lunch time staff were making sure that service users had enough to eat. They were allowed as much time as they needed to complete their meal and looked to be enjoying it. Meal times are flexible depending on service users daily activities. Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 11 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): None of these standards were assessed at this inspection EVIDENCE: Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 12 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): 22 and 23. Service users are protected from harm. EVIDENCE: A complaints procedure is given to service users /representative when the first come to live at the home. A record of complaints is kept and shows that any issues raised are taken seriously and dealt with promptly. No complaints have been recorded since the last inspection. Staff receive training in abuse awareness. Staff spoken to knew to report any suspicions of abuse to a manager. Robust procedures are in place to prevent any financial abuse of monies that are held in the home on behalf of service users. Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 13 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 and 30 Service users live in a clean, comfortable and safe home. EVIDENCE: The home provides spacious accommodation for service users. This includes a lounge, music room and a large kitchen/diner on the ground floor. There is a sensory room in the basement. The home is clean and comfortable. It is decorated and furnished to a very good standard. The décor and furnishings reflect a “young persons” type of household. There has been a significant programme of redecoration and refurbishment since the last inspection. A range of checks is completed on a regular basis to make sure that the house is safe and secure. Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 14 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): 35 Service users needs are met by a well-trained staff team. EVIDENCE: Staff training records examined showed a comprehensive training programme. All staff complete a home specific induction programme followed by Learning Disability Award Framework accredited induction within the first 6 weeks. A range of other training including Health and safety training is provided. This provides staff with the knowledge and skills to perform their duties in a competent manner. Staff spoken to thought that the training provided is good. The training staff receive and evidence required to maintain accreditation with the National Autistic Society means service users receive care from a staff team with expertise in providing care for people with autism. Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 15 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): 39 and 42 Service users best interests are promoted and reflected in the service provided. EVIDENCE: The situation regarding the quality assurance remains the same as at the last inspection whereby the home has a formal quality assurance system called Continuous Quality Improvements. This includes details about improvements to be made over a 12-month period and progress is monitored closely. Identified areas for action include staff training, environment and service users targeted ambitions. The main source of input is from staff that work in the home. Information is gathered through talking to service users, knowledge of their likes and dislikes, staff meetings and reviews. However the views of service users and their representatives are not formally gathered as part of the CQI process. Senior management is still considering the requirement made at the last inspection. The deadline to comply with the requirement is the 30th April 2006. Records examined showed that there are systems in place to ensure the health and safety of service users and staff. Regular routine servicing of systems and appliances are carried out.
Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 16 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 X 33 X 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X X X X 1 X X 3 X Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 17 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 YA39 Regulation 24 Requirement The registered person must implement a system, which reviews the quality of the service provided, and which includes the views of service users and their representatives. A copy of the report of such a review must be made available to the Commission for Social Care Inspection. Timescale for action 30/04/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Alderson Road 12 DS0000007877.V275551.R01.S.doc Version 5.1 Page 18 Commission for Social Care Inspection York Area Office Unit 4 Triune Court Monks Cross York YO32 9GZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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