Inspection on 30/04/07 for Ayresome Terrace

This inspection was carried out on 30th April 2007.

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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Ayresome Terrace 01/03/06

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 Hebrew Rawlins Key Unannounced Inspection 30th April 2007 08:30 Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 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.V329060.R01.S.doc Version 5.2 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.V329060.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ayresome Terrace Address 17 Ayresome Terrace Leeds West Yorkshire LS8 2BJ 0113 2888848 0113 2888848 ayresometerrace@c-i-c.co.uk www.c-i-c.co.uk. Community Integrated Care 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) Sarah Louise Crossley Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st March 2006 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. The current fee is £1025.23 per week with additional charges for hairdressing, toiletries and general leisure. Information about the home can be found at the company head office Community Integrated Care and at the home. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk This unannounced key inspection took place at 8.30am on the 30th April 2007. The purpose of the visit was to monitor standards of care in the home. The home completed a pre-inspection questionnaire. The information provided has been used in the preparation of this report. The methods used at this inspection included a tour of the building, looking at care records, observing working practices and talking with people living in the home and staff. Information gained from a pre-inspection questionnaire and the home’s service history records were also used. Survey cards were sent out to visiting professionals to the home and left at the home for other visitors and relatives. Comments from the survey cards can be found throughout this report. There were no visitors to the home on the day of the visit. Feedback at the end of this inspection was given to the manager. Thanks are extended to everyone who contributed to the inspection and for the hospitality during the visit. Requirements and recommendations made during this visit can be found at the end of the report. What the service does well: The service is well managed and there are clear lines of communication and accountability within the company, which makes sure people that use the service, receive the care and support they need. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 6 The needs of all people that use the service are assessed before any service begins and there are systems in place to refer people on for a re-assessment of their needs if necessary, making sure their needs can be met at all times. Thorough staff recruitment and selection procedures are in place, which help to protect service people from any form of abuse and all complaints are taken seriously. Staff have a very good knowledge of the people’s needs and respond well to them. The atmosphere in the home is warm, friendly and welcoming. Staff interact well with those living in the home and treat them as individuals. One of the people living in the home was part of the interview panel of a prospective worker, making sure the views of people living in the home are heard. Staff are good at encouraging family involvement and supporting people to keep in touch with family and friends. People receive a good standard of health care. The staff team work well with the health professionals involved with people living in the home. What has improved since the last inspection? What they could do better: The medication sheets must be signed when medication is administered. If not this could create a situation where medication is given twice which could be a risk to people’s health. Some parts of the home are showing signs of wear and tear, tiles damaged, toilet seat needs replacing, sealant around the shower needs replacing and the electrical extractor fans in the toilets are in need of deep cleaning. The garden is in need of attention and areas of the fencing needs repairing. Copies of the operations manager’s reports (regulation 26) must be regularly sent to the Commission for Social care Inspection. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 8 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.V329060.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The information provided about the service is good and gives people that are considering using the service the opportunity to decide whether or not the home can meet their needs. The assessment procedure is thorough and people can be sure that the home will not offer to provide a service unless the staff are able to meet their needs. EVIDENCE: The Statement of Purpose provides good information about the service, which helps people decide whether or not the home can meet their needs. The manager did the needs assessment for the last person who moved into the home. The people living in the home and his relatives had been consulted and contributed to the assessment. The moving process was tailored to meet this person’s needs and the needs of the relatives. Visits and overnight stays were arranged and a moving in date agreed by all concerned. The assessment period also considered the needs of the other service users. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 10 All the people in the home have a contract with the organisation that outlines all the terms and conditions. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are met by support plans and risk assessments that provide clear detailed instruction. EVIDENCE: People living at the home are encouraged to continue to make decisions about their day-to-day lives. Staff have a good understanding of the effect on individuals when these abilities are in decline and provide appropriate support. In all of the care records sampled there was evidence of health needs being met, by dental appointments, optical prescriptions and visits to GPs. Due to the complex needs of some of the service users it is difficult to hold formal meetings with them. Some service users do not use verbal Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 12 communication so are observed for their body language and facial expressions in response to questions. The local advocacy service provide advocacy for people in the home. Risk assessments are in place to reflect lifestyle choices. In discussion with people living in the home, it was clear that they are supported to take risk in order to enjoy life’s experiences. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to make choices about their lifestyle and supported to develop their life skills. Appropriate activities are arranged and a good, healthy and varied diet is offered. EVIDENCE: Service users are involved in various activities each week. This includes, day centres, Gateway clubs, pubs, restaurants, theatre, cinema, leisure centre, sport events and walks in the countryside. Families also supplement the input that staff can give, taking their relatives out and involving them in their own families’ lives. Staff support service users with their diverse needs. A service user enjoys watching horse racing, the home has acquired SKY television so that person Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 14 can enjoy watching the races whenever he wants. A male member of staff is key worker to this person and goes out with him to place the odd bet. Staff were seen to support people with courtesy and thought for their dignity. They said they are encouraged to get involved in household task. Menus showed that there is plenty of choice and variety. Pictorials menus are used to help service users choose what they want to eat. The mealtime is relaxed, and people in the home are able to eat in comfortable surroundings. Staff were seen to make available to people using the service drinks throughout the day. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff place a good deal of importance on continuity of care, whether that be from the staff team at the home or from hospital or community based health care professionals. EVIDENCE: Where a potential risk has been identified a risk assessment is completed and action is taken to safeguard people using the service and staff. Policies and procedures are in place to enable staff to report new or potential areas of risk. Staff support people using the service with their personal care needs in private and with dignity. The level of detail in support plans on how personal care and health related tasks are to be carried out makes sure the people using the service needs are fully met. The support plans have details of any health professionals that people within the home see. These include, GP, dentist, chiropodist, psychiatrist, psychologist and optician. Records are kept of any health appointments and their outcome. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 16 No people using the service manage their own medication. The Medication Administration Records (MAR) sheets were checked; it was found not all were signed when medication is administered. This could create a situation where medication is given twice which could be a risk to people’s health. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by a robust complaints procedure and adult protection procedure. EVIDENCE: The organisation’s recruitment procedures follow good practice guidelines, including the thorough vetting of staff before employment. Adult Protection training is included in the basic training that all staff undergo. The home’s Policy File contains good detailed procedures to follow. The manager welcomed the opportunity to address concerns before they grew into serious complaints. No complaints have been received by the home in the past year. There are appropriate procedures in place for the safe management of personal allowance, the records showing that proper accounting procedures are adhered to. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is tidy throughout and offers a safe environment in which service users are able to live in comfort. EVIDENCE: All of the peoples’ bedrooms were seen during this inspection. They are all decorated to reflect each person’s individuality within their own room. Each room seen was very different in style, colour and personalisation. There are no en suites but all rooms have a wash hand basin with some needing deep cleaning. There are sufficient communal sanitary facilities available for people living in the home. However they are showing signs of wear and tear, tiles damaged, a toilet seat needs replacing, sealant around the shower needs replacing and the electrical extractor fans in the toilets are in need of deep cleaning. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 19 In general the premises are clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in the home and during the inspection they wore protective clothing when assisting people to the toilet The home is decorated and furnished to a good standard throughout and the communal rooms offer a safe and comfortable space for the people living there. Nothing was seen during the inspection that could cause a hazard to service users. The building externally is well maintained; however at the time of the inspection the garden needed attention and areas of the fencing needs repairing. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35 and 36. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff are competent and well supervised to meet the needs of people living in the home. These people are protected by the home’s recruitment procedures. EVIDENCE: All staff said they felt they had a good team and the manager was very supportive. They said communication and teamwork within the home were great. Staff receives regular supervision. There is a clear commitment to making sure that the staff are trained and competent. They have had training in promoting independence, update in fire and abuse. Well over half of the staff team have achieved an NVQ (National Vocational Qualification) in level 2 or above. Duty rotas indicated that there are sufficient care staff on duty to meet the needs of the people living at the home. Care staff do the cooking and cleaning Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 21 with the support of the people living in the home. In some parts of the home deep cleaning is needed. The recruitment files looked at on the day of the visit for recently employed staff were up to date. All the necessary checks are carried out before staff start work at the home. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 40, 41, 42 and 43. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and has a competent management team. This means that the interests of the people living in the home are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The home has an experienced manager who has almost completed her NVQ level 4 in care and Registered Manager Award. Her target completion date is December 2007. She has a BTEC National Diploma in Social Care and has worked in residential care supporting individuals with learning difficulties in excess of 12 years. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 23 She offers good leadership to staff and has good systems in place to make sure people living in the home are supported and cared for properly. The operations manager makes regular visits and reports on the conduct of the home. This involves talking to people living in the home and staff about the home. The manager was told copies of these reports must be regularly sent to the Commission for Social Care Inspection. Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting and water temperatures. Maintenance records are kept and health and safety training is well maintained. The home has a comprehensive range of policies and procedures in place to ensure health and safety. The manager makes sure staff are familiar with these and asks them to sign them when read. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 3 4 5 CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 3 4 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 4 x ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 2 28 x 29 x 30 2 STAFFING Standard No Score 31 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score LIFESTYLES Standard No Score 11 3 12 4 13 3 14 3 15 3 16 4 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 4 x 3 3 3 3 Version 5.2 Page 25 Ayresome Terrace DS0000001418.V329060.R01.S.doc Are there any outstanding requirements from the last inspection? NO 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 YA27 YA30 Regulation 23 Requirement Some parts of the home are showing signs of wear and tear, as detailed in the body of the report. These issues must be dealt with to make sure people live in a good environment. Timescale for action 30/06/07 2 YA43 24 Copies of the operations 30/06/07 manager’s reports (regulation 26) must be regularly sent to the Commission for Social Care Inspection. This should make sure the service is being monitored and the CSCI kept informed. 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 Refer to Standard YA20 YA24 Good Practice Recommendations The medication sheets must be signed when medication is administered. The garden is in need of attention and areas of the fencing DS0000001418.V329060.R01.S.doc Version 5.2 Page 26 Ayresome Terrace needs repairing. Ayresome Terrace DS0000001418.V329060.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 DS0000001418.V329060.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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