Inspection on 21/02/06 for Allerton Avenue

This inspection was carried out on 21st February 2006.

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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Allerton Avenue 21/11/08

Allerton Avenue 29/11/06

Allerton Avenue 20/09/05

Allerton Avenue 07/03/05

Allerton Avenue 24/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Allerton Avenue 3 Allerton Avenue Moortown Leeds West Yorkshire LS17 6RE Lead Inspector Linda Trenouth Unannounced Inspection 21st February 2006 11:20 Allerton Avenue DS0000001411.V283236.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 Allerton Avenue DS0000001411.V283236.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. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Allerton Avenue Address 3 Allerton Avenue Moortown Leeds West Yorkshire LS17 6RE 0113 288 8577 0113 2888577 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) www.c-i-c.co.uk. Community Integrated Care Mr Paul Cordy Care Home 4 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (2) of places Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. The 2 places for LD(E) are for the service users named in connection with the variation application December 2003 20th September 2005 Date of last inspection Brief Description of the Service: Allerton Avenue is a large detached house in an area of similar houses in a suburb of Leeds providing care for up to four male and female adults with learning disabilities. The home does not provide nursing care. There are separate kitchen, laundry, dining and lounge areas on the ground floor. All the service users occupy single rooms with two communal bathing facilities located on the ground and first floors. The house has large well-maintained gardens and is located near to local shops, transport and amenities. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was on the 20th September 2005 and there have been no additional visits made to the home. This was an unannounced inspection carried out by one inspector who was at the home from 11.20 until 16.00. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care for the residents. The methods used at this inspection included looking at care records; observing working practices, reviewing the environment and talking to the staff and residents. Comment cards were sent to the home to provide residents and visitors with the opportunity to comment on the service. Feedbacks from comment cards are included in this report. The manager for the home was on annual leave at the time of the visit therefore feedback of the requirements and recommendations were given to the staff at the end of the inspection. The manager was later contacted by telephone. Requirements and recommendations made from this visit can be found at the end of the report. What the service does well: The staff make sure that all residents make meaningful decisions about their lives, the life planning and life books are person centred and regularly reviewed. The choices that people make are well considered and staff make sure that they choose from an extensive range of good quality activities and experiences. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 6 The staff meet regularly and have good support and supervision from their manager. The home also exceeds the requirement for staff training in general training and the National Vocational Qualifications. What has improved since the last inspection? What they could do better: The home is generally well maintained and homely with the exception of the main entrance to the home, which is via a porch. This area has continued to deteriorate and is not maintained to a satisfactory standard. The woodwork is in a poor state and rain leaks through the roof causing a slip hazard. This area is also used as a storage area; storage should be kept to a minimum to make sure there is a safe clear exit at all times. It was felt that lighting levels must be reviewed in the home to makes sure that stairways and a passage ways are safe for all people living and visiting the home. There are other minor maintenance problems, which are commented on within the report. The home supports residents by administering their medication, it was felt that present storage of the non-prescribed medication was unsafe and must be moved to an area, which minimises the risk to residents. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 7 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. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 8 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 Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 9 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. Residents individual aspirations and needs are assessed to make sure that they lead a safe and fulfilling life. EVIDENCE: Record keeping is of a good standard and the assessment and life planning records provide comprehensive detail and a clear structure to the care provided at the home. There was clear evidence from the records and discussions with residents and staff that residents were actively involved and contributed to the assessment process. Communication was supported by the use of graphics and pictorial images, which represented key areas of the residents life. Allerton Avenue DS0000001411.V283236.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, 8 and 9. Care planning is thorough and residents are very much involved in the process. Residents are supported in making decisions about all aspects of their daily lives including managing risks. Residents are supported in making decisions in their daily lives by staff, relatives and advocates. EVIDENCE: Residents are meaningfully involved with the running of their home and lives. The care planning is person centred and genuinely includes the individual in all the decision-making. The staff only give support where necessary, the preferences of the individual are clearly central to the care. Record keeping is of a good standard and the assessment and care planning provide good detail and a clear structure to the care provided at the home. Staff must make sure however that they sign all entries that they make in the residents care record. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 11 Each resident is also involved in regular reviews, which take place with professionals from the learning disabilities team, day service staff, relatives advocates and staff from the home. These reviews encompass all aspects of the residents lives and clearly show how agreements are reached about risk management. Residents with the support of staff said that they enjoyed living at the home and described how they spent their days and the activities they did beyond the home. One resident showed me her invitation to her 50th birthday that the staff had made with her and explained that her sisters were organising a big party, which all her friends would be invited too. She was also very happy with her pet cat Tiddles, who arrived at the home last year and is clearly a welcome addition to the home. Allerton Avenue DS0000001411.V283236.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): 11, 12, 13 and 14. Staff support residents to become part of, and participate in, the local community, in accordance with their wishes. Residents are encouraged to participate in appropriate social and leisure activities. Residents lead fulfilling lives outside as well as within the home. EVIDENCE: Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 13 Residents are encouraged to help with the domestic tasks within the home. They are supported to clean their own rooms and help with laundry, shopping and preparing food. One resident regularly sets the table for the main meal. The staff are positive and imaginative in furthering the residents skills within the home and aim to provide a varied and fulfilling programme of activities both within the home and wider community. One resident was enjoying watching TV in the lounge and other residents spent time with the staff helping with the lunch. Staff were observed engaging and including residents throughout the cooking and preparation of the meal. Staff said that all the residents have different activities that they are involved with during the week. Some attend day centres and T.A.C.T. during the week. Two of the residents are involved with I.L.S. Inclusive Learning Services who provide support to learn new skills. Residents weekly activities included dancing, yoga, horse riding, bowling, swimming, walks, art classes and days out to local places of interest. The Staff had helped residents plan their holidays. In the last year these holidays have included Prague, Spain and the activities park Oasis. One resident regularly attends church on Sunday and others attend the Gateway Club and a new social club called Octopus Club, based in Leeds. The residents use all local facilities, including hairdressers, shops, restaurants, pubs, cinemas and theatres. Allerton Avenue DS0000001411.V283236.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): 19 and 20. The residents health is regularly assessed and reviewed to make sure that needs are not overlooked. Medication procedures and staff training make sure that residents are protected when taking medicines, but the present storage of non prescribed medications compromises safety. EVIDENCE: Residents have a health plan, which assesses their individual health needs and was regularly reviewed. The good organisation and management of this made sure that essential health needs were not overlooked. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 15 The staff have received training in medication and have a good understanding of the policies and procedures. The medication records were well maintained and the storage of prescribed medication held safely. Concerns were raised however regarding the storage of other medication that is not prescribed. The bathroom cupboard storing this medication was not locked during the visit. Storage of medication in the bathroom is not safe and must be removed and held with the main medication cabinet. The use of communal creams must cease, where a resident requires cream these must be either prescribed by the GP or individually bought and labelled. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 16 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): Not reviewed. EVIDENCE: Not reviewed. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 17 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): 25, 26, 27, 29 and 30. The residents live in a comfortable home with generous communal space to suit their needs and lifestyles. Maintenance of the home is mostly well supported, however the porch/ entrance was now in urgent need of repair. EVIDENCE: The home is continually refurbishing the decor, furniture and carpets in the home. The lounge, dining room, hall, stairs and bedrooms have all had new carpets fitted since the last inspection. The bathrooms and toilets were generally well-maintained and protected residents privacy with the exception of the down stairs shower and toilet area where the blind to the window was no longer working. Paper towels must also be available to promote and maintain the control of infection. The light switch pulley also needs replacing in the first floor toilet and the extraction fans need cleaning. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 18 Concerns were raised about insufficient lighting levels to the 2nd floor of the room. One residents bedroom and the staff sleeping in room are on this floor. The lighting level must be enhanced to ensure that the stairs and rail banisters can be clearly seen. The entrance used by the residents to their home is in a poor state, during the inspection the rain was coming through the roof onto the floor below creating a slip hazard. The woodwork clearly was in need of repair or replacement. Efforts should be made to minimise the storage of items in this area to ensure that the area is a clear route through and does not compromise fire safety. This may also help improve the appearance of the entrance of the home. Food must not be stored in this area and all food must be lifted off the floor wherever stored. In contrast the home beyond the porch area is homely, comfortable, well decorated and furbished. Residents were clearly relaxed and comfortable in their home. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 19 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): 31, 32 and 33. There is a stress on staffing at the home with two out of the eight staff posts now vacant and the manager working additional shifts whilst being on duty for other homes. The residents are supported by trained and supervised staff who benefit from clarity of role and responsibility. EVIDENCE: Regular supervision was provided to all staff and annual appraisals were undertaken. During supervision and appraisal individual and group training needs are identified. Staff confirmed that they have formal “handovers”, between each shift and regular staff meetings. The staff confirmed that new staff induction training at the home and additional training is provided regularly. The home is carrying two staff vacancies and the manager of the home is working hands on throughout all shifts and sleeping in at the home. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 20 The vacancies carried at the home represents a quarter of the total care staff and raises concerns regarding the effects on staff and the residents. The manager is also on call for other homes in the group and hours rotad for the home are regularly being used for organisation business beyond the home. The permanent staff are covering extra shifts but adjustments to residents activities are having to be made to accommodate staff shortages. Staffing levels must meet the needs and planned activities of the residents. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 21 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): Not reviewed. EVIDENCE: Not reviewed. Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 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 x 23 x ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 3 x LIFESTYLES Standard No Score 11 3 12 3 13 4 14 4 15 4 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x 3 2 x x x x x x x x Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 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. 1 2 Standard YA20 YA20 Regulation 13 13 Requirement The non-prescribed medication must be stored in the main medication cabinet. The use of communal creams must cease. The residents G.P. should individually prescribe creams or alternatively individual creams must be purchased and labelled. The Porch/ entrance is in need of urgent repair and refurbishment. Consideration needs to be given to the use of the porch area for storage. The route through must be kept clear at all times. Lighting levels must be sufficient in the home to maintain health and safety. A working blind must be fitted to the bathroom window. Timescale for action 23/04/06 23/04/06 3 4 YA24 YA24 23 23 23/04/06 23/04/06 5 6 YA24 YA27 23 23 23/04/06 23/04/06 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 Good Practice Recommendations DS0000001411.V283236.R01.S.doc Version 5.1 Page 24 Allerton Avenue Standard Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 25 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 Allerton Avenue DS0000001411.V283236.R01.S.doc Version 5.1 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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