Inspection on 12/01/06 for Ardsley House

This inspection was carried out on 12th January 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 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

Ardsley House 12/06/08

Ardsley House 31/07/07

Ardsley House 14/08/06

Ardsley House 21/09/05

Ardsley House 01/11/04

Ardsley House 02/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

Pennine Camphill

Muston Road (70)

Grayling

The Cornerstone

John Street Nursing Home

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

CARE HOME ADULTS 18-65 Ardsley House 55a Royston Hill East Ardsley Wakefield West Yorkshire WF3 2HG Lead Inspector Karen Westhead Unannounced Inspection 12th January 2006 09:30 Ardsley House DS0000001413.V274862.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 Ardsley House DS0000001413.V274862.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. Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ardsley House Address 55a Royston Hill East Ardsley Wakefield West Yorkshire WF3 2HG 01924 835220 01924 872618 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) J C Care Ltd Mrs Robina Richmond Care Home 16 Category(ies) of Learning disability (16) registration, with number of places Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st September 2005 Brief Description of the Service: Ardsley House is owned by J C Care, which is a subsidiary of Craegmoor Health Care. The care home is registered to provide accommodation and care services for up to sixteen residents with a learning disability. However, two double bedrooms are being used for single occupancy, therefore fourteen residents can live at Ardsley House at present. Two of the bedrooms have en-suite facilities, comprising of a toilet, hand washbasin and a shower. There are two communal bathrooms available to residents. Ardsley House is situated on a busy main road. It is set back with gardens to three sides. There is a good range of local amenities and shops and the area is well served by public transport. The home is within easy reach of major motorway links. There is ample parking available to the front and the rear of the house. There is a single storey detached building in the back garden. This is used as a day centre. An activity organiser, who is employed for thirty hours a week, works with residents in the centre and uses the building as a base. A support worker assists when necessary. The home is spread over two floors. There is no passenger lift or level access to the home, however some ground floor bedrooms are available. Respite care is not provided in the home. Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection year runs from April to March and within that twelve-month period, the Commission for Social Care Inspection (CSCI) is required to undertake a minimum of two inspections of all regulated care homes. This was the second inspection of this home for the 2005/2006 inspection year. The last inspection was carried out on 21st September 2005. One inspector undertook the inspection, which was unannounced. The visit started at 9.30am and finished at 1.30pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents and in accordance with the law. At the last inspection four requirements were highlighted and one recommendation. One of the requirements had been addressed leaving three requirements and one recommendation outstanding. During the visit, the inspector spent a large proportion of time speaking with residents and staff. A number of documents were inspected during the visit and all communal areas of the home were seen. Some residents showed the inspector their bedroom. This was taken as an opportunity to talk with residents in private. All staff on duty were either spoken to or observed carrying out their work. CSCI comment cards and post-paid envelopes were left, to be distributed to both residents and their relatives. After completion these are returned to the CSCI. Feedback about the inspection was given to a senior member of staff at the close of the visit. What the service does well: Residents are involved as much as possible in the running of the home. The home has good adult protection procedures and staff are aware of their roles in this area. Recruitment and selection procedures are robust and ensure the employment of suitable staff. The home provides a good balance between educational, social and recreational activities. There is also time for residents to relax in their own personal space. Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ardsley House DS0000001413.V274862.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 Ardsley House DS0000001413.V274862.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): 1, 2, 3, 4 and 5 Residents are given sufficient information to help them make a choice about living at Ardsley House. However, not all of the residents had a signed contract or statement of terms and conditions. Information could be better presented for those with limited abilities. Residents are assessed prior to admission to make sure the home is suitable for them and that their needs can be met. EVIDENCE: None of the current resident group need specialist equipment to be able to live in the home comfortably. They have access to specialist services such as advocacy groups, educational placements, including an onsite day centre and have ample opportunities to mix with people of their own age. Some literature and documentation is presented using symbols and pictures. The manager should continue to develop this to include other key documents bearing in mind the limited skills of the current resident group. Information held on file was not up to date and did not reflect the care being delivered or the altered needs of some residents. Some documentation was not signed or dated. Not all residents have an up to date and signed contracts or statements of terms and conditions. This should be in place to confirm what services are to be provided and specify exactly what the fee covers. One resident had moved bedroom since the file was set up, this was not recorded Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 9 or the reason for the move and whether any consultation had been made with the resident involved. Written evidence was seen to show that residents had been offered introductory visits to the home before deciding whether to stay or not. Admissions are arranged according to individual circumstances. There is a trial period to allow for settling in and to make sure the home is suitable and staff can meet the needs of the resident. No respite care is provided Ardsley House at present. Ardsley House DS0000001413.V274862.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 and 10 Residents do not know their assessed and changing needs are reflected in their care plans. Information is significantly out of date. Residents are empowered in making decisions however this is not reflected in the records seen. Information held is kept securely. Staff are bound by their contracts of employment to respect confidentiality. EVIDENCE: Care files showed that risk assessments had been carried out, however, some were out of date and had not been amended to give an accurate picture of the risks involved and the action to be taken to minimise this. The management of risk is designed to promote independence rather that impose undue restrictions on individuals lives. However, the documentation in some cases was a few years out of date and therefore included the risks, which were evident before the resident was admitted and had made progress. Much of the information held had not been reviewed. The last entry for family contact or outing in many files dated back to the beginning of November 2005. Some significant care needs were highlighted in the needs assessment carried Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 11 out prior to admission. However there is no mention of this in the continuing care plan or the risk assessment in place. Issues such as self-injurious behaviour and physical aggression are two examples. Resident information is held securely. Staff are aware of their responsibilities and know that information given to them in confidence may have to be shared with senior staff or others if necessary. All staff have a contract of employment and sign to say they will respect the confidentiality procedure as part of that. Ardsley House DS0000001413.V274862.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): 13, 14, 16 and 17 Residents have appropriate support from staff, outside agencies and other professionals in order for them to lead a fulfilling lifestyle inside and outside the care home. Daily routines are intended to promote independence and choice however observations on the day of the visit showed that this was not always adhered to. EVIDENCE: Local community services and out of area amenities are accessed by the majority of residents. Not all residents need escorting. Some residents use public transport. An eight-seater car has been provided for the homes use. This had been delivered the day before the inspection and residents were keen to be taken out in it. Staff are proactive in their efforts to ensure residents attend leisure activities, educational placements and therapeutic recreation. Overall there is good organisation around leisure. Residents are enabled to research and choose their individual activities. Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 13 During the course of the visit residents were seen interacting with staff about their days activities. Appropriate support was being offered and the inspector gained the impression that this practice was the norm. Residents with specific and complex needs are provided with specialist support from other agencies. Residents, who were able to share their experiences, confirmed they were satisfied with the levels of activity provided/organised. Those residents with limited understanding and speech were supported appropriately and systems were in place to monitor their involvement in organised and ad hoc events. On arrival at the home five residents were at different stages of finishing their breakfast in the main dining room. They confirmed they had had a leisurely time getting up and some had enjoyed a bacon sandwich. The main meal was planned for teatime and a hot and cold snack were available for dinnertime. One resident said they had certain food preferences and that staff tried their utmost to provide his chosen diet. Food, which has been opened, should be dated and appropriately covered when being stored. Staff did not routinely knock on doors leading to toilets prior to opening them. On one occasion a resident was using the facility. This practice is not acceptable. Ardsley House DS0000001413.V274862.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): 20 and 21 There is a flexible approach to daily routines, which supports residents with their personal care needs and health care support. Residents receive appropriate medical treatment for short and long term conditions. The medication records in the home were not being maintained appropriately. A policy relating to care of the dying is in place. EVIDENCE: A random selection of care plans were seen during the course of the visit. As stated in the previous section, additional work is required to ensure records reflect the care and attention provided and that a structured plan of care is in place. It was evident that the medical records were not being maintained properly. Omissions were noted in the record being kept. There is a policy in the home, which relates to care of the dying. Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 15 There is a flexible approach to daily routines. Residents described a ‘typical’ day, which involved a choice about getting up, if they were not having to attend an appointment or prearranged event, and going to bed when they wanted. Residents, who were able to comment, said staff were always available to help them get in and out of the bath. Staff were seen to offer suitable advice and guidance about personal hygiene and matters, which could affect others in the home. However, they should remain mindful about the need to knock on doors before entering areas being used by residents, particularly bathrooms, toilets and bedrooms. Records showed residents were being offered appropriate treatment from doctors, hospital consultants and other professionals. Residents, during conversation, referred to their visits to the doctor’s surgery. They were able to see the doctor in private if they wished, receive treatment and had their medication reviewed regularly. The doctors surgery used has a total of eight doctors, including one female and a practice nurse who co-ordinates amongst other things routine health screening. Ardsley House DS0000001413.V274862.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): 22 and 23 The home has a robust adult protection procedure and all staff have been trained to understand the subtle aspects of abusive behaviour and the action to be taken if suspected abuse is reported to them. EVIDENCE: All staff have been trained in the protection of vulnerable adults. Training varies from base line in house training to a one-day session provided by an external trainer. In the last six months there has been one adult protection issue in the home. This resulted in a member of staff being suspended pending an investigation. There has been one complaint made to the home directly in the last twelve months. This was resolved and appropriate action was taken. Staff on duty were able to describe the action to be taken in the event of concerns being raised or if they observed bad practice. They were fully aware of the whistle blowing and complaints procedure. Residents said they were confident if they complained about anything it would be ‘seen to it’. The staff team said they would try to resolve ‘grumbles’ within the home before they developed into a complaint. Ardsley House DS0000001413.V274862.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): 26, 27 and 29 Resident’s bedrooms promote independence. Bathrooms and toilets provide adequate privacy and facilities are suitable. No specialist equipment is required to maximise independence. A replacement washer is required. EVIDENCE: Some residents agreed to show the inspector around the building and into their bedrooms. Areas seen were clean, tidy and appropriately furnished. Checks of fire safety equipment and fire drills were being completed as required. None of the current resident group needs specialist equipment in order for them to be able to use the facilities correctly. On the day of the visit staff were having difficulties dealing with laundry. A washer was faulty, having been repaired recently. The replacement washer should have a sluice cycle in accordance with the changing needs of residents and to comply with health and safety procedures. Ardsley House DS0000001413.V274862.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, 35 and 36. Staff have clear roles and responsibilities. The organisation must make sure all staff receive up to date training to allow them to carry out their work competently. There are sufficient staff on duty to cater for the needs of the current resident group. EVIDENCE: The training records demonstrated there had been a lapse in the training staff had received over the last six months. New starters had not completed their induction programmes and there were no definite plans about who was to take them through this. Despite the recent staff changes the remaining staff have been able to keep the home staffed by working additional shifts and supporting each other. Ardsley House DS0000001413.V274862.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): 39 and 43 The home does not have a quality assurance system although it is visited on a monthly basis by a senior manager from the organisation. No concerns were raised about the financial viability of the home. More should be done to protect money held in the home. EVIDENCE: A senior manager from the organisation visits the home monthly and prepares a report. Copies are provided to the commission. It was discovered during discussions that there is open access to the safe by all staff. A system must be put in place to reduce the risk of errors being made. The registered provider must also make sure the amount of cash held in the home does not exceed the permitted amount according to the insurance cover in place. Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 20 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 3 2 3 3 3 4 3 5 2 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 X 25 X 26 3 27 3 28 X 29 2 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 3 15 X 16 2 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 3 X X 3 X X X 2 Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 21 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 YA6 Regulation 15 Requirement The registered provider must make sure that the care plan is kept under review and maintained in a way, which reflects the care being provided to meet the residents needs. This requirement is outstanding from 21st September 2005. The registered provider must make sure that unnecessary risks are identified and so far as possible eliminated. Documentation regarding risk assessments must be up to date and accurate. This requirement is outstanding from 21st September 2005. The registered provider must make sure that staff are appropriately supervised. This requirement is outstanding from 21st September 2005. The registered provider must make sure that all residents have an up to date and signed contract/statement of terms and conditions. DS0000001413.V274862.R01.S.doc Timescale for action 12/03/06 2. YA7 13 12/03/06 3. YA36 18 12/03/06 4. YA5 5 21/03/06 Ardsley House Version 5.1 Page 22 5. 6. YA17 YA16 16 12(4)(a) 7. YA20 8. 9. YA35 YA43 13 and 17(1)(a) Schedule 3.3(i) 18 13 10. YA29 16(2)(f) The registered provider must make sure that food is stored appropriately. The registered provider must make sure staff respect the dignity and privacy of residents at all times. The registered provider must make sure medication records are completed in full and accurately. The registered provider must make sure staff receive the appropriate training. The registered provider must make sure adequate systems are in place with regard to access to the safe and the amount of money held within it. The registered provider must provide a replacement washer with sluice cycle. 12/03/06 12/03/06 12/03/06 23/04/06 12/03/06 21/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA6 Good Practice Recommendations The manager should continue to develop the production of literature in alternative formats, including pictures and symbols for those residents with limited communication skills. This recommendation is outstanding from 21st September 2005. Ardsley House DS0000001413.V274862.R01.S.doc Version 5.1 Page 23 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. 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