Inspection on 01/03/06 for Ayresome Terrace

This inspection was carried out on 1st March 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Ayresome Terrace 30/04/07

Ayresome Terrace 25/10/05

Ayresome Terrace 28/02/05

Ayresome Terrace 15/09/04

Ayresome Terrace 17/02/04

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

CARE HOME ADULTS 18-65 Ayresome Terrace 17 Ayresome Terrace Leeds West Yorkshire LS8 2BJ Lead Inspector Kathleen Firth Unannounced Inspection 1st March 2006 10:15 Ayresome Terrace DS0000001418.V283890.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 Ayresome Terrace DS0000001418.V283890.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. Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Ayresome Terrace Address 17 Ayresome Terrace Leeds West Yorkshire LS8 2BJ (0113) 2888848 0113 2888848 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 Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th October 2005 Brief Description of the Service: Ayresome Terrace is a large detached house in a residential area made up of similar houses. There is nothing to show that it is a residential home. Care is provided for four younger adults who have a learning disability. Accommodation is provided on two floors, each resident having their own bedroom. There is a lounge, dining room and a quiet room for the use of the residents that offer a comfortable and safe space for them. Bathing and showering facilities are available. The home is close to local amenities and is accessible by public transport. Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over two and three quarter hours by one inspector on Thursday 2nd March 2006. The inspector looked around the building, spoke with staff and management, observed residents, and examined residents’ records including care plans, staff files, menus, Medication records and Contracts. The manager was available throughout the inspection. What the service does well: What has improved since the last inspection? Staff have made sure that all residents are able to enjoy facilities within the home. Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 6 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. Ayresome Terrace DS0000001418.V283890.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 Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 5 All prospective residents have an assessment of need done before they are admitted to the home. Each resident has an individual contract containing the terms and conditions of the home. EVIDENCE: One resident is moving out of the home due to decreased mobility causing him problems getting around the house. This is a slow process as he is being gradually introduced to his new home. He alongside his dad have been fully involved in choosing a more suitable place and they are both happy with where he is going to live. Five people were put forward for the place and the manager looked at all of them. She then carried out an assessment of need on the one thought to be the most suitable. The manager met with everyone concerned with his care and has worked a shift where he is living to obtain a good picture of his needs. He and his family can be sure that his needs will be met at the home otherwise the manager would not have agreed his admission. He will start visiting the home once the present resident has left and his admission will take as long as the man needs to feel happy and secure about moving in. The young man will be able to choose the colour he would like his room to be. All residents have an individual contract that contains the terms and conditions of the home. It explains what they can expect from the service and although Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 9 staff explain the contract to the residents more information needs to be in a pictorial form to aid understanding. Ayresome Terrace DS0000001418.V283890.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, 8, 9 The care plans accurately reflect the needs of the residents and areas of risk are highlighted. Residents are included in decision making within the home. EVIDENCE: Each resident has a comprehensive care plan in place that gives information about their needs. There was evidence seen that the residents and families are involved in drawing up the care plans. Very specific risk assessments are in place alongside the required coping strategies. The plans are reviewed on a regular basis and updated as required. Six monthly reviews of care are held that involve everyone concerned with the welfare of the resident. Whenever possible staff involve the residents in decision making within the home. Despite verbal communication being difficult amongst the residents staff give them information and assist them to make choices. They have just been involved in choosing a new colour scheme at the home along with new flooring. Staff observe the residents’ behaviour and body language to judge if they are unhappy with anything or do not want to do a particular thing. Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 11 Residents regularly have time away from the home and the staff team are very good at volunteering to accompany them. One resident who enjoys walking has just been to the Lake District with two staff members. Risk assessments are done wherever required and staff accept the right of the resident to take risks and they are able to balance this with their duty of care. Ayresome Terrace DS0000001418.V283890.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): 14, 15, 16, 17 Staff arrange suitable leisure activities for the residents. Residents’ rights are protected at all times. A good, healthy and varied diet is served at the home. EVIDENCE: The residents enjoy a wide range of activities arranged by the staff team. Bowling, shopping, going to the cinema, shopping and pub meals are just some of these. One man was going to a party of a woman he attends day care with and he was looking forward to this. Staff recognise the right of residents to refuse to do things if this is their choice e.g. attend day care. Staff support residents to maintain contact with their families where possible. One man goes to stay with his mother each weekend and one father visits his son on a regular basis. Families can be as involved in their relatives care as they choose. The home offers a good, varied and nutritious diet to the residents. Pictorial menus are used to help the residents choose what they want to eat. There is always a choice offered if the resident does not like the main meal offered. Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 13 Staff said that none of the residents have any eating problems and appropriate help is given to them to make sure they are able to enjoy their meals and receive enough nutrition. Ayresome Terrace DS0000001418.V283890.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): 18, 20, 21 The residents’ health needs are monitored and regularly updated. Staff are aware of the residents’ needs. Residents’ medication is correctly managed. EVIDENCE: All of the present residents require some level of personal care and this is offered in the privacy of their own room or the bathroom whichever is the most appropriate. Staff were seen to treat the residents with respect and to be tactful when dealing with personal needs of the individual. Specialist equipment is obtained for the residents where required to try and maintain their independence. None of the residents are able to manage their medication and the home has a comprehensive policy and procedure in place to deal with this. All staff have completed a nationally recognised award on Handling and Administering Medication. The home also offers their own training and no one is allowed to deal with medication until this has been done. Staff’s competence in dealing with medication is reviewed every six months. The Boots system is in place and all records seen were correctly maintained. One resident is a diabetic and the staff deal with their condition very well. The District Nurse has taught two members of staff to draw up insulin that is given to the resident by staff who have been trained to do so. The insulin is stored in the fridge, clearly labelled as per the District Nurses instructions. Several checks are made before the Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 15 insulin is administered to make sure that everything is correct. This procedure has all been risked assessed and is felt to be the best way of handling this situation. No pressure has been put on staff to learn how to administer the insulin and where there is no one available the District nurses come to do so. The lady’s diet is well controlled and staff have a good awareness of how to handle the diabetes. The manager has started to look at a book titled “What to do when I die” to make sure that decisions are made with the resident and family and staff know what to do when a resident dies. Residents can stay at the home if they become ill provided their needs could still be met. The manager will consult with the GP, District Nurses and any specialist services that may be required to make sure that the resident can be nursed at the home. Ayresome Terrace DS0000001418.V283890.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, 23 The home provides an environment in which the residents are protected. Residents and their relatives have their views listened to, taken seriously and action taken to resolve them. EVIDENCE: The home has a comprehensive complaints policy and procedure in place and all residents are given a copy of these. This information needs to be in a pictorial format although the manager said that these particular residents would still require an explanation of what it means. The manager is confident that relatives and residents will talk to her or the staff if they have any concerns or worries. Staff regularly monitor residents’ behaviour and demeanour for any changes that may indicate that they are unhappy. All staff have received Adult Protection training and the home has a policy in place to deal with this. Staff are able to recognise the signs and symptoms of abuse and know what action to take. There is also a Whistle Blowing policy at the home that all staff are made aware of. Risk assessments and coping strategies are in place to prevent self-harm. There have been no complaints or Protection of Vulnerable Adults (POVA) referrals in the past twelve months. Ayresome Terrace DS0000001418.V283890.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): 24, 25, 26, 29, 30 The home offers a safe environment for the residents and provides them with suitable accommodation. EVIDENCE: The home has recently been decorated throughout and offers a warm, comfortable and safe place for the residents to live. It is clean, hygienic and tidy throughout and nothing was seen that could cause a hazard to residents, staff or visitors. A clinical waste collection service is in place. There is a fish tank in the quiet room for the residents to enjoy. The large garden area is enclosed making it safe for the residents to use. The manager is thinking of having a summerhouse built to offer extra sitting space for the residents. The staircase has two handrails to offer assistance to residents. The bedrooms are all of a good size and are decorated and furnished to suit the individual resident’s needs. One resident has sensory equipment around as he enjoys listening to music. There is a walk in shower available for residents unable to use the bath. One resident uses a rollator to walk around the home. Communal areas in the home offer sufficient space for all the residents to use and be comfortable. Ayresome Terrace DS0000001418.V283890.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, 34, 36 Residents are protected by the robust recruitment policy in place. Training and support are offered to the staff team. EVIDENCE: Staff undergo a two-week induction programme and have a six-week probationary period. This can be extended if the manager feels it is necessary. Staff are able to access appropriate training and are encouraged to attend relevant courses. Three people are working towards NVQ level 3 and some have achieved Level 2. The manager and senior care officer are working towards the NVQ assessor award but there are some problems with the training providers that are holding them up. The company operate a centralised recruitment policy that looks towards employing the most suitable people for individual posts. All interviews are carried out under equal opportunities legislation. Two new members of staff are due to start working at the home in the near future. Two written references, Criminal Records Bureau (CRB), POVA, Visa and work permits are all checked before an appointment is made. Regular staff supervision sessions and staff meetings are held. Written records of the sessions are maintained. Staff meetings are held at various times to try to enable as many people as possible to attend. Minutes are made available to all staff. Staff say that the manager offers them good support. Ayresome Terrace DS0000001418.V283890.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): 37, 38, 39, 40, 43 The home is well managed with the interests of the residents seen as important to the manager and staff and safeguarded at all times. EVIDENCE: The manager has worked with this client group for over ten years and holds a B Tech. National Diploma in Social Care and NVQ Level 3 in Promoting Independence. She is presently working towards the Registered Manager’s award. She offers good leadership to staff and good interactions were observed between her, residents and staff. The manager has made some very positive changes to the residents’ care plans. All records seen were correctly maintained and stored. Quality Assurance questionnaires are sent out on an annual basis from the company head office. The manager will receive the results from the national survey. The Service Manager completes monthly Regulation 26 visits to the home when she audits different topics and examines files. Personnel from head office carry out unannounced audits at the home each year. Staff files Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 20 contain all the required information including recent photographs. There is no adverse information concerning the Company’s financial affairs. Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 21 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 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 3 27 X 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X 3 3 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X 4 3 3 3 3 3 X X 3 Ayresome Terrace DS0000001418.V283890.R01.S.doc Version 5.1 Page 22 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Ayresome Terrace DS0000001418.V283890.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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