Inspection on 21/09/05 for Ardsley House

This inspection was carried out on 21st September 2005.

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 4 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 12/01/06

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 WF3 2HG Lead Inspector Karen Westhead Unannounced 21 September 2005 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 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 Stationary 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 J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ardsley House Address 55a Royston Hill East Ardsley Wakefield WF3 2HG Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 01924 835220 01924 872618 J C Care Ltd Mrs Robina Richmond Care Home Only 16 Category(ies) of Learning disability (16) registration, with number of places Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 1st November 2004 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 service users with a learning disability. However, one double bedroom is being used for single occupancy, therefore fifteen service users 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 service users. 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 service users 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 J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 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 first inspection of this home for the 2005/2006 inspection year. The inspection, which was unannounced, was undertaken by one inspector. The visit started at 9.30am and finished at 3.45pm 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 requirements. The last inspection of this service was in on 1st November 2004. At that time three requirements and one recommendation was made. All requirements have now been addressed. During the course of the visit, the inspector spent a large proportion of time speaking with residents, staff members and the manager. A number of documents were inspected during the visit; some areas of the home were seen, such as bedrooms and communal areas. All staff on duty were spoken to and observed carrying out their work. Individual and group discussions were held with residents. A number of CSCI comment cards and post-paid envelopes were left, to be distributed to residents and their relatives. After completion these are returned to the CSCI. In addition, information leaflets were given to residents with a brief description of the CSCI function and details of how to contact the lead inspector. Feedback about the findings from the inspection were given to the manager at the close of the visit. What the service does well: The home provides some information in pictures and symbols to assist those with limited communication skills. Residents are involved as much as possible in developing personal care plans, which aim to achieve their expectations. Residents are assessed to ensure risk management is maintained. However, some improvements are required in these areas. The home has good adult protection procedures and staff are aware of their roles in this area. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 6 The home has facilitated the training of staff. Recruitment and selection procedures are robust and ensure the suitable employment of 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. 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 J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 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 standard(s) None of the standards were looked at during this visit. EVIDENCE: Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8 and 9 The information held in care plans was on the whole well ordered and provided in a chronological order. Residents are assisted in making choices in their lives. Those residents who were able to communicate verbally talked about their care plans and their individual expectations. EVIDENCE: The care plans are identical in format. Information is split into different sections enabling the reader quick access to specific details. Health records are maintained giving a clear breakdown of contact with other professionals and a brief description. Care files showed that risk assessments had been carried out, however, some were out of date and had not been amended to show 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 ‘previous’ risks when the individual involved had not been worked with or enabled to make progress. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 10 Some staff are better than others at daily recording and care plan evaluation. Care delivery, which was explained and in some instances observed, was not accurately reflected in the care plan documentation. The manager acknowledged that this was an area, which required improvement. Staff had recently undertaken a care planning course and systems were in place to ensure staff support was provided. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 15 and 17 Educational, social and recreational activities provide a good balance and allow opportunities for residents to enhance existing skills and knowledge. EVIDENCE: On the day of the visit residents were either attending the day centre, adult placement centres, shopping, visiting the doctor, undertaking tasks in the home and grounds or relaxing at home. Four residents were busy making last minute plans for a holiday in Florida the following day. One resident had received information in the post and was discussing the enclosures with the manager. The inspector was informed of a new project involving residents and staff. The previously unused land at the rear of the home has been organised in such a way that a small ‘farmyard’ has been created. Livestock such as poultry, goats and a pony have been moved onto the site. Appropriate housing and fencing is in place and residents were involved in painting and erecting further facilities. There was an atmosphere of excitement about the development of the project and residents were showing a clear interest and all becoming Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 12 involved. The person supplying the livestock is not employed at the home. However, residents are accompanied by a member of staff when carrying out any of the tasks. The area is also overseen from the home and regular supervision is available if required. Residents who were in and around the home congregated at lunch time to share their meal. A hot snack was provided. The main meal of the day is provided in the evening. Residents are involved in the preparation and delivery of food according to their abilities. Residents can develop and maintain intimate personal relationships with people of their choice. Information and guidance is provided to help residents make appropriate decisions. Residents meetings are organised and minutes kept. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 and 19 Overall, care files give a good indication of the level of care each person receives. Some staff need more support to ensure the information held is accurate and up to date. EVIDENCE: One care plan confirmed one resident had been admitted as an emergency placement. The care plan and assessment had been completed by a social worker who had known the resident previously. According to the daily events log some residents had had their medication reviewed. This is undertaken as a matter of course. Staff are sensitive to the subtle changes in residents behaviour/condition and act promptly to any changes. Staff were seen to respect residents personal space. Residents have keys to their bedrooms if they wish and those able to comment confirmed their privacy was respected at all times. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 14 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 standard(s) 23 The home has a robust adult protection procedure and all staff have received training. Staff are able to understand the subtle aspects of abusive behaviour. EVIDENCE: In house training has been provided for all staff on adult protection. This is reiterated during induction training for new staff and during staff supervision. Two members of staff spoken with were able to describe the action to be taken in the event of any concerns. The home has, in the past, handled allegations of suspected abuse or inappropriate behaviour in a professional way and in accordance with in house procedures. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 15 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 standard(s) 24, 25, 28 and 30 The home provides a safe and comfortable environment. Fixtures, decor and fittings are domestic in style. All improvements and maintenance is dealt with by the registered provider. The manager sets an annual projected budget for this. Appropriate systems are in place to account for any unforeseen events, which require capital expenditure. EVIDENCE: The communal areas and some resident bedrooms were seen during the visit. Some residents were at home during the visit and using either their own rooms or communal areas. The home was found to be clean and fresh. There were no requirements highlighted with regard to the premises. However the suggestions by the manager about providing additional bathing facilities to two areas of the home are advocated by the inspector. The home has a rolling programme of refurbishment, renewal and redecoration. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 16 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32,33,34,35 and 36 A routine training programme allows staff to enhance and develop their skills and knowledge. Formal supervision is inadequate and must be provided more regularly. The home has a robust recruitment and selection procedure. EVIDENCE: The inspector spoke to three staff members in private and the remainder in a group. From their comments and the discussions held it was clear that they felt supported in their work and had clear guidance from the manager. Staff confirmed their attendance on courses and the work they were undertaking on the day of the visit. Newly appointed staff detailed what had been covered during their induction training. Staff were seen carrying out domestic and caring duties. One member of staff dealt with a potentially sensitive matter with a resident. Her manner was calm and professional. Solutions to the issue were highlighted and the resident was given a clear explanation and ample opportunity to exercise a choice. The manager confirmed that formal supervision had lapsed. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 17 A random selection of staff files were examined. This included the files of three new starters. All the necessary documentation had been completed and checks made. A number of staff are employed from overseas. There are difficulties at times with their spoken language skills. The manager should remain mindful of this and ensure the difficulties are not compromising resident care and understanding. The staff roster showed adequate numbers of staff on each shift, including night and day duty. The manager is supernumery and works in a flexible manner to ensure she is available at key times during week days and weekends. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 40, 41 and 42 The management structure offers staff the opportunity to develop skills and maintain a supportive role for residents. The health, safety and welfare of residents is safeguarded without unnecessary restrictions. EVIDENCE: The home has a full time manager who is registered with the CSCI. She has a wide range of skills and has worked in the care sector for a significant number of years. She is supported by senior staff who take their role seriously and work in tandem with the manager. The fire training records showed that all staff had received training. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 19 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 2 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x 3 x 3 Standard No 11 12 13 14 15 16 17 3 4 x x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ardsley House Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 3 x J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 20 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. 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 service users needs. 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. The registered provider must ensure that staff employed are able to communicate effectively with residents and staff. The registered provider must make sure that staff are appropriately supervised. Timescale for action before 17 November 2005 2. YA7 13 before 17 November 2005 3. YA33 19 before 17 November 2005 before 17 November 2005 4. YA36 18 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 J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 21 Ardsley House literature in alternative formats, including pictures and symbols for those residents with limited communication skills. Ardsley House J52 J03 S1413 Ardsley House V201419 210905 Stage 4.doc Version 1.40 Page 22 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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