Inspection on 01/11/05 for Aykroyd Lodge

This inspection was carried out on 1st November 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Aykroyd Lodge 05/12/07

Aykroyd Lodge 05/12/06

Aykroyd Lodge 10/05/05

Aykroyd Lodge 30/11/04

Aykroyd Lodge 20/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Aykroyd Lodge The Cresecent Reedley Nr Burnley Lancashire BB10 2LX Lead Inspector Mrs Julie Playfer Unannounced Inspection 1st November 2005 09:15 Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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 Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Aykroyd Lodge Address The Cresecent Reedley Nr Burnley Lancashire BB10 2LX 01302 813100 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) Voyage Ltd inc. Thelma Turner Homes Mrs Michelle Jones Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home, must at all times, employ a suitably qualified and experienced manager, who is registered with the ational Care Standards Commission. The home must maintain the following staffing levels as a minimum at all times: One support worker to every two service users during the waking day. One supporte worker on waking watch duty and one support worker on sleeping duty during the night. 10th May 2005 Date of last inspection Brief Description of the Service: Aykroyd Lodge is registered with the Commission for Social Care Inspection to provide accommodation and personal care for up to six adults (aged 18 - 65) with a learning disability. The home comprises of a large detached property, set in its own grounds, in a residential area in Reedley, Burnley. Spacious accommodation is provided in six single bedrooms, all of which have an ensuite facility. There are two lounges, a dining room and a dining kitchen. The garden is extensive, well maintained and accessible to residents. There is wheelchair access to the home at the main entrance, which is on the side of the building. There are limited car parking facilities. The home is located approximately half a mile from Brierfield town centre. The staffing levels form part of the conditions of registration. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was the second unannounced inspection of 2005 and took place over one day. At the time six people were living in the home. During the course of the inspection the inspector met with four of the residents. One person was able to make comments about the home. The views of other residents were gained from observation of their reactions and communications with staff. The inspector spoke with the manager and the staff on duty. A partial tour of the premises took place and a number of documents and records were viewed. Since the last inspection, the registered manager had left employment with the home and a new manager had been appointed. What the service does well: What has improved since the last inspection? Since the last inspection, a lot of information had been sought about the resources in the surrounding area as a result the residents had tried various different activities and had joined new clubs. An additional member of staff had been employed to carry out cooking, cleaning and laundry duties. This meant the care staff could spend more time doing activities with the residents. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 Page 6 Improvements had been made to the overall management of medication and all records seen were complete and up to date. A programme had been established to ensure staff received supervision at least six times a year. This allowed staff to discuss their training and development needs with their line manager. 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. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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 Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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 and 5 Residents were provided with useful and informative information about the services and facilities provided in the home. Resident’s needs were properly assessed and reviewed. EVIDENCE: Written information was available for residents in the form of a service users guide. The guide was presented in a suitable format. In addition, an audiotape had been made for residents to listen to. The staff also confirmed they had discussed the contents of the service users guide with the residents. There had been no new residents admitted to the home since the last inspection. However, it was evident from the case tracking process that a full assessment of needs had been carried out prior to admission for existing residents. The assessments had been carried out by the previous carer and the social worker. The previous manager had collated this information and produced an overall assessment. Specialist services had been involved and consulted. All residents had been issued with a contract/terms and conditions. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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): 6 and 9 The care planning system fully addressed the needs of the residents and provided clear guidance to staff on how these needs were to be met. EVIDENCE: The residents had an individual plan, which reflected their health and welfare needs. Detailed instructions were set out for staff to ensure all needs were met. Where necessary the care plans were supplemented by behaviour management guidelines, which were designed to provide a consistent response to behaviours, which challenged others and the service. The guidelines focussed on positive behaviour and the use of distraction. The residents were involved in their care plan as much as possible and where a resident couldn’t indicate their verbal agreement, close observations were made and the plan was reviewed as necessary. The plans were reviewed at least every six months with the resident and any supporter or professional who needed to be involved. Plans were reviewed at other times if the residents’ needs changed. It was the practice of the home to support responsible risk taking and policies stated that the role of staff was to facilitate independence wherever possible. Detailed risk assessments and management strategies covered activities indoors and in the wider community and were included on residents’ plans. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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): 11, 12, 13, 14, 15, 16 and 17 Residents were provided with very good opportunities to engage in a wide range of appropriate activities and were supported to use community facilities. The residents maintained strong links with their families, which were supported by the manager and staff. Arrangements were in place to ensure the residents participated in the life of the home and their rights were respected. EVIDENCE: The individual plans and care records demonstrated that residents had opportunities to maintain and develop practical life skills. Where necessary tasks had been broken down and achievable goals had been set. Residents pursued an extensive range of activities both inside and outside the home, which was detailed on individual activity schedules. Activities outside the home included; bowling, trips to Towneley Park, walks in the local area and shopping in Burnley town centre. Since the last inspection, information had been sought about resources available in the local area and as a result the residents had tried different activities and joined new clubs. The high staffing levels allowed for more individual and small group activities. On the day of Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 Page 11 inspection two residents went shopping with two staff to purchase winter clothing. One person had also commenced a full time course at a local college, which he attended with staff support. The residents were supported to maintain relationships with their families and where necessary the staff assisted with transport. At the time of the visit two residents were away visiting their families. The residents had unrestricted access to the home and grounds. The residents were also able to use their room at any time should they wish to spend some time in private. The meals followed a six week menu, which provided the residents with a variety of different food. The inspector observed residents being consulted about their preferences for the lunchtime meal and noted they were presented with a range of options to assist them with their choice. One resident spoken to said the meals were “good”. The staff maintained individual records of meals served to the residents. Since the last inspection an additional member of staff had been employed for 20 hours a week to carry out cooking, cleaning and laundry tasks. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The residents’ healthcare needs were identified and met. Personal support was provided in a manner, which respected the residents’ rights to privacy and dignity. Appropriate systems were in place to handle medication, however, all medication must be stored at the appropriate temperature. EVIDENCE: The residents’ individual care plans set out the personal support each resident required and provided details of how this support was to be delivered. The home had an intimate care policy and procedure for each resident, which emphasised the residents’ rights to privacy and dignity. Staff told the inspector the routines were flexible and were primarily designed to meet the needs of the residents and their plans for the day. Healthcare needs were appropriately assessed and were included in the care plan. There was evidence to indicate the residents had access to NHS services and the advice of specialist services had been sought as necessary. Since the last inspection, improvements had been made to the overall management of medication in the home. The medication administration record corresponded accurately to the prescription labels, medication had been administered in line with the prescriber’s instructions and protocols had been devised for the administration of medication prescribed “as necessary”. In Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 Page 13 addition a record of receipt had been maintained of all medication received into the home, all prescribed medication was available on the premises and instructions of where to apply creams was easily accessible. However it was noted that temperature of the drugs cabinet was high and there had been no arrangements put in place for controlled drugs. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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 the following standard(s): 22 and 23 Systems were in place to ensure any concerns of residents would be acted upon. Appropriate policies and procedures and staff training were in place to respond to any allegations or suspicions of abuse. EVIDENCE: The complaints procedure was included in the service users guide and had been verbally explained to residents. The procedure had also been recorded on audiotape and this had been played for some of the residents. The residents, who were not able to communicate their views verbally, were closely observed and their reactions noted. There was evidence of these observations in the care notes and in the placement reviews. Since the last inspection the manager had received one complaint, which was being investigated at the time of the visit. Notification of the complaint had been sent to the Commission. (The complaint did not involve the care and support of the residents). Staff had received training in the protection of vulnerable adults. Written policies and procedure were also available for reference. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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 the following standard(s): The residents were provided with a spacious, comfortable, safe and wellmaintained home. However, the residents’ bedrooms must be kept clean at all times. EVIDENCE: Aykroyd Lodge is a large detached house set in it’s own grounds. It is located in a residential area in Reedley, near Burnley. Accommodation is provided in six single bedrooms, all of which have an ensuite facility. There is a bath in each of the ensuites. Communal space is provided in two lounges, one dining room and a dining kitchen. All rooms provide facilities in excess of the National Minimum Standards. The bedrooms had been decorated and furnished according to personal taste. Residents were able to use their rooms at any time, should they wish to spend time pursuing their own activities. One area of a resident’s bedroom required cleaning. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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 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): Staff had access to a wide range of training opportunities, which gave them a good understanding of their role and the needs of the residents. Improvements must be made to the recruitment and selection procedure and induction training in order to safeguard residents. EVIDENCE: Staff were issued with job descriptions, which set out their roles and responsibilities. It was evident the job descriptions were linked to meeting the needs of the residents. From discussions with staff during the inspection, it was evident they had a good understanding of the residents’ needs and knew the residents well. Staff referred to the residents in respectful terms and were observed to interact in a positive and pleasant way. The staff rotas indicated that the staffing levels were regularly reviewed and additional staff were placed on duty, where necessary, to meet the needs of the residents. The recruitment and selection of new staff was underpinned by the organisation’s Equal Opportunities Policy. The files of three recently employed staff were inspected. All three had completed an application form and had attended for an interview. Relevant checks had been obtained from the Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 Page 17 Criminal Records Bureau. However, there were shortfalls noted in the recruitment procedure, these included gaps in employment history without a satisfactory explanation of the gaps, a reference not being sought from a previous employment which involved working with vulnerable adults and no statement by the staff as to their mental health. Staff were offered a range of training opportunities and information was available in respect to the care and support of people with a learning disability. Each member of staff had a training assessment and profile and there was an overall training development plan for the staff team as a whole. Whilst plans were in place for all staff to receive LDAF training by February 2006, it was noted that none of the new staff had completed an in-house induction workbook. Staff meetings were held on a regular basis and minutes were seen during the inspection. The meetings gave the opportunity to staff to share experiences and develop teamwork. A programme had been established to ensure the staff received supervision at least six times a year and had an annual appraisal of their work. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39 and 42 The quality assurance systems must be developed to ensure the service is run in the best interests of the residents. The management approach promoted positive relationships between the staff and the residents and the overall atmosphere was open and friendly. Appropriate policies and procedures were in place to safeguard the health and safety of the staff and residents EVIDENCE: Since the last inspection the registered manager had left employment with the home and a new manager had been appointed. The new manager had applied to be registered with the commission and this application was being processed at the time of the visit. The manager had achieved an NVQ level 4 in management and planned to enrol on a course to achieve an NVQ level 4 in care. The management approach was consultative and there were systems in place to consult both staff and residents. Relationships within the home were positive and staff spoke about the residents with respect. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 Page 19 The manager had continued to use the monthly audit tool to monitor systems within the home, for instance the review of care plans. However, an annual development plan based on continuous self-monitoring had not been developed. Satisfaction surveys had not been distributed to residents, their families/representatives or professional staff involved with the residents. Staff received health and safety training, which included moving and handling, food hygiene, first aid and fire safety. The gas and electrical systems were serviced at regular intervals. To minimise the risk of scalding all water outlets were fitted with preset valves. Window restrictors and radiator covers were fitted, as appropriate. The fire log demonstrated staff and residents had participated in regular fire drills. The fire extinguishers had been serviced in January 2005. The home had public and employers liability insurance cover in place against loss or damage to the assets of the business and business interuption costs. A financial plan had not been devised. Aykroyd Lodge DS0000054542.V252925.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 4 4 4 4 4 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 4 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 X 3 1 2 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Aykroyd Lodge Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X 3 X DS0000054542.V252925.R01.S.doc Version 5.0 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 2 3 Standard YA20 YA30 YA34 Regulation 13 23 (2) (d) 19 Sch 2 as amended 18 24 Requirement All medication must be stored at the appropriate temperature. All areas of the home must be kept clean at all times. All records and documentation relating to the recruitment of new staff must be collated and maintained in line with the requirements of the Regulations. New staff must receive induction training which meets with “Skills for Care” specifications. An annual development plan must be produced, which is based on a systematic cycle of planning, action and review reflecting aims and outcomes for residents. (Previous timescale – 1st August 2005 – not met). Satisfaction questionnaires must be distributed to residents and/or their family/representatives and professional staff involved with the residents. Results from the questionnaires should be collated, published and inform future planning for the home. (Previous timescale – 1st August 2005 – not met). DS0000054542.V252925.R01.S.doc Timescale for action 01/11/05 01/11/05 01/11/05 4 5 YA35 YA39 01/11/05 01/03/06 6 YA39 24 01/02/06 Aykroyd Lodge Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA20 YA37 YA43 Good Practice Recommendations Arrangements should be put into place for the storage and administration of controlled drugs, should residents be prescribed this medication in the future. The manager should achieve an NVQ level 4 in care. A financial plan should be devised for the home. 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