Inspection on 25/10/05 for Ayresome Terrace

This inspection was carried out on 25th October 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 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 01/03/06

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 Unnnounced 1.15 pm 25 October 2005 th 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. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Community Integrated Care Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 24/02/04 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 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over three hours by one inspector on Tuesday 25th October 2005. The inspector looked around the building, spoke with staff and management, observed residents, examined residents’ records including care plans, staff rosters, menus and staff files. The manager and staff were helpful during the inspection and happy to join in. Residents were happy for their rooms to be looked at. What the service does well: What has improved since the last inspection? Staff have been trained to administer insulin if they were willing to do so. The district nurse prepares the insulin for administration and it is stored appropriately. Two members of staff now hold the NVQ assessors award. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 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 20050915 J52 S1418 Ayresome Terrace V1972215 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 Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 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) 1, 2, 4, 5 The residents have a degree of choice of placement, however Healthcare professionals and the placing agency give them guidance. EVIDENCE: There have been no recent admissions to the home but the manager explained the process. Admissions are tailor-made for the individual and take as long as required. The resident may make as many visits to the home as they choose until they are happy to move in. During this period the resident is encouraged to help choose the décor for their room and the style they wish it to be furnished and equipped in. During the admission period staff are able to make sure that the new person will fit in with the other residents. This is seen as very important as it is such a small group. The manager is able to meet the prospective resident prior to their first visit and assess their needs as well as receiving information from health and social care professionals involved in the individual’s care. Parents and other carers are involved in the assessment process. All of the residents are given an individual contract giving them the terms and conditions of the home and what they can expect from the service. These contracts are kept in the individual resident’s file at the home. Pictures are used to some extent in the information supplied by the home but, this needs to Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 9 be extended to make sure that the residents are able to understand what is being shown to them. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 9, 10 The records accurately reflect the needs of the residents and areas of risk are highlighted. Good communication makes sure that the residents’ needs are met. EVIDENCE: All residents have a comprehensive care plan in place that gives information about their needs. Evidence was seen that the residents are involved in drawing up the plans. Very specific risk assessments with the required coping strategies are in place and there was evidence that the plans are reviewed and updated on a regular basis. Six monthly care reviews are held with the residents and their families or representatives invited to attend. Wherever possible the residents make decisions about their lives although with this particular group this involvement is sometimes minimal. Staff give as much information as possible to the residents and assist them to make informed decisions. It is usually by their behaviour and body language that residents tell staff they do not want to do a particular thing. There is a fund available to pay for residents’ holidays and they can add to this if they so choose. They have been to several places this year including Ireland Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 11 and more time away is planned. Residents, their families and representatives are made aware that they can look at their records if they want to. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 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 standard(s) 11, 12, 13, 15, 17 Appropriate activities are arranged for the residents. Residents are supported to keep contact with family and friends. EVIDENCE: All of the residents attend some type of day care. Three attend TACT facilities whilst one goes to a local centre. One person attends a local community centre on one half day each week to help with his communication skills. The residents go out and about in the local community and are accepted by the local people. Two of the residents have close family ties and either visit them at home or go out with them on a regular basis. Three residents have advocates from the Leeds Advocacy service. The rights of the residents are respected at all times. The residents are encouraged to eat a good, nutritious and well balanced diet at all times. They choose their own breakfast and lunch including a pack up where needed. The main meal of the day is eaten in the evening and the menu is presented in a picture format to assist the residents to make their Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 13 choice. One resident is diabetic and the staff use portion control along with a healthy diet to make sure her condition is kept under control. Staff showed a good awareness of the need to maintain control of the resident’s condition. The dining room is large enough to accommodate the residents at meal times and offers a comfortable setting for them to enjoy their meals. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 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 standard(s) 18, 19, 20 The health care needs are monitored and regularly updated. Residents are treated with respect and their privacy and dignity maintained at all times. Staff are aware of the residents’ needs. EVIDENCE: All of the residents require some level of personal care and this is offered in the privacy of the bathrooms or their own room. Staff were seen to be very tactful when dealing with the toileting needs of the residents. Specialist equipment is provided where required for the residents. The residents are registered with one GP practice and receive good support from the local healthcare team. The Diabetic nurse offers regular contact and support to one of the residents. She is always ready to offer advice and support to the staff helping them monitor and manage the resident’s condition. The residents all see a Psychologist on a regular basis and Psychiatric support is available where required. Arrangements are in place for residents to receive chiropody treatment and have eyesight tests as required. The residents attend the local Dental Hospital if they require treatment. None of the residents are able to manage their own medication and the home has a policy and procedure in place to do this for them. The home uses the Boots system that involves tablets being on various coloured sheets for Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 15 different times of the day. Medication was seen to be stored correctly and all records up to date. The District nurse comes two or three times per week to draw up insulin and this is then given to the resident by staff at the required times. Insulin was seen to be stored in a safe way, clearly labelled as per the district nurse’s instructions. The insulin is stored in the fridge before the nurse has drawn it up. Staff who are willing to give the insulin injections have been trained to do so. No pressure has been placed on staff to do this but arrangements are in place to make sure someone is always available to do so. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 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 standard(s) 22, 23 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve them. The home provides an environment where residents feel protected. EVIDENCE: All residents have a copy of the complaints procedure and the manager feels that they, their family or representative are able to approach her or the staff if they have any concerns or worries. Staff monitor the residents’ body language, behaviour and demeanour for any changes that may indicate unhappiness. Some residents have an advocate who will be involved if no family member is available if there is any problem. Staff have attended the “No Secrets” training in addition to in house Adult Protection training and are aware of what to look for regarding abuse. The home has a Whistle Blowing policy in place. Behavioural charts are kept for one particular resident and these are sent to a psychiatrist involved in his care. The psychiatrist then offers guidelines to the staff on how to deal with this resident. The psychologist involved with all the residents’ care is also able to give staff guidelines on how to deal with particular behaviours. The home has waking night staff on duty in order to make sure the residents are safe at night. Financial records kept on behalf of the residents were seen to be correctly maintained and checked on a regular basis. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 27, 28, 30 The home offers a safe environment for the residents and provides them with suitable accommodation. EVIDENCE: The home offers a very comfortable, homely environment with the fixtures and fittings being of a very good standard. It was found to be very clean and tidy throughout and the manager said that redecorating of the communal areas is on the maintenance plan for this year. There is a large fish tank in the quiet room for the residents’ enjoyment. One resident spends much of his time in this area, as he feels safe there. The lounge and dining room are large enough for all of the residents to have enough space to be comfortable. The large garden area is enclosed and safe for the residents to use. There are two handrails on the staircase to offer assistance to residents. There are sufficient toilets to meet the needs of the residents. Bathing and shower facilities are available for the residents. The bedrooms are all of a good size and decorated to suit the individual. Furniture is chosen to suit the individual resident as is the equipment provided. One resident has lots of sensory equipment around his room as he enjoys sound and music. The home Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 18 has a clinical waste contract in place and nothing was seen that could cause a hazard to residents, visitors or staff. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 33, 34, 35 Staffing levels were adequate and geared to meet the needs of the residents. Training and support are provided for the staff team. Residents are supported and protected by the recruitment procedure in place. EVIDENCE: All staff understand their role and responsibilities as well as those of their colleagues. The home operates a key worker system and the manager tries to match the residents with a care worker. There were sufficient staff on duty at the time of the inspection and rosters confirmed that this is normal practice. The company has a bank list so staff can be accessed if required. They also operate an “on call” system so extra people can be called in if there is a need. There is an approved agency list within the company to ensure only suitable staff are used. Apart from two new staff everyone at the home has achieved or is working towards a National Vocational Award. There are two assessors working at the home so this has helped achieve this. Staff are able to access suitable training courses. The company operates a central recruitment procedure and looks to employ the most suitable people for individual posts e.g. location or hold a driving licence. Candidates are able to visit the home and meet with the residents. Interviews are conducted as per the equal opportunities Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 20 procedures. Before being allowed to start working at the home people have to undergo the required checks including, CRB, POVA, Visa, Work permit and provide two written references. They then undergo a two-week induction programme and have a six-week probationary period that can be extended if necessary. All required information was present in the staff files including up to date photographs. Formal supervision sessions were seen to be in place with written records being kept. Staff meetings are held every four to six weeks. The manager holds these at different times to allow as many people as possible to attend. There is a written agenda for people to contribute to and minutes are available for all staff. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 39, 41, 42 The home is well managed, the interests of the residents are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager has over ten years experience working in this area of care, holds several pertinent qualifications and is working on the Registered Manager’s award. She reviews care practises each month and her manager carries out the required regulation 26 visits when different topics and files are looked at. All records seen were properly maintained and stored correctly. The company send quality assurance questionnaires to residents, relatives, representatives and staff on an annual basis. Results from one of these were seen to be very positive. Financial records kept on behalf of residents were seen to be correctly maintained and receipts were available for all monies spent. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 22 All staff are trained in health and safety although the manager has overall responsibility for this area within the home. Fire bells are tested weekly, all major appliances tested by outside contractors annually, and PAT testing done as required. Soap and towels were seen in the toilet areas along with gloves and aprons. The laundry is done on the premises with everything being washed at the correct temperatures and the home has a control of infection policy in place. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 23 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 3 2 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 x 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ayresome Terrace Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 x 3 x 3 3 x 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 24 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 Regulation Requirement There are no requirements from this inspection 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. 1. Refer to Standard YA 23 Good Practice Recommendations Staff need to make sure that residents are able to enjoy all the facilities in the home and are not prevented from doing this by particular individuals. Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 25 Commission for Social Care Inspection Aire House Town Street Riodley Leeds, LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Ayresome Terrace 20050915 J52 S1418 Ayresome Terrace V1972215 Stage 4.doc Version 1.40 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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