Inspection on 21/06/05 for 138 Bradford Road

This inspection was carried out on 21st June 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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

138 Bradford Road 23/06/09

138 Bradford Road 04/04/07

138 Bradford Road 23/11/05

138 Bradford Road 28/02/05

138 Bradford Road 05/10/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

Whitwood House

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

CARE HOME ADULTS 18-65 Bradford Road 138 Bradford Road Pudsey Leeds LS28 6EP Lead Inspector Barbara Grell Unannounced 21 June 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Bradford Road Address 138 Bradford Road Pudsey Leeds LS28 6EP 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) 0113 2393142 0113 2393142 Sense (North) Care home 3 Category(ies) of Learning disability (3) registration, with number Sensory Impairment (3) of places Physical disability (3) Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: no Date of last inspection 28.02.05 Brief Description of the Service: Bradford Road is a service that provides residential care to a maximum of three younger adults with sensory impairment and other disabilities. The house is situated in Stanningley that is well served by public transport and parking is provided within the grounds and on road. The house can be accessed via ramps and two of the three bedrooms are situated on the ground floor. There are gardens to the front and rear including a decked patio area and raised flower beds. Trail rails are fitted to assist service users with orientation around the house and garden. The service is provided by SENSE, a national voluntary organisation that specialises in the care of individuals with sensory loss. Whilst a resident at Bradford Road service users are able to use other local resources provided by SENSE including training and educational opportunities provided within resource centres. Bradford Road is a domestic premise that has been converted to provide care. The fixtures, furnishings and fittings are domestic in style whilst offering equipment in order to meet the needs of the service users. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and undertaken on 21 June 2005 between 9:15 and 12:30. There were two staff on duty and support provided by another registered manager within SENSE whilst the proposed and acting registered manager was on holiday. There was one vacancy at the home and two service users were at home during the inspection. The following methods were used in inspecting this service. One case study was undertaken and all care documentation evaluated. service user was observed during breakfast and in interacting with staff. The One audit was undertaken of a service users manual handling and mobility needs. This included and audit of staff skill and the environment and mobility and handling equipment. Two personnel files were inspected to judge the recruitment and vetting of staff. The revised statement of purpose was inspected and the content evaluated against applicable Regulations and standards. The food provision and menu planning, storage and preparation of food were inspected. Survey materials were provided to the case study’s next of kin and GP. Both were returned and the outcome will be incorporated within the body of the report. What the service does well: The premises are domestic in style and residents furnish and equip their bedroom as they wish and in line with there needs. Hobby equipment and materials are apparent around the home. The aims of the organisation are well met in this community setting. The staff team enable service users and assist offering many choices and areas for development and learning. Relatives praise the level of care and service. The residents are enabled to make choices and decisions and the care and services are based on needs and take account of personal preferences, wishes and aspirations of the individual. Residents known signs and symbols are used and communication needs are well addressed. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 6 The care and services are of a high standard. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bradford Road J52 S1425 Bradford Road V233883 210605 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 Bradford Road J52 S1425 Bradford Road V233883 210605 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 The statement of purpose provides the required information. This document is available in the home. Current service users have been subject to full assessment prior to admission. EVIDENCE: The statement of purpose has been revised after changes within the registration that separated Bradford Road and a number of other small establishments to become separate care homes. The statement of purpose meets the current standards and the requirements of Schedule 1 of the Regulations. A number of minor changes will be suggested by CSCI by letter in due course. A Service User Guide must be forwarded in order to audit the content during the next inspection. The current service users had been subject to multi-disciplinary assessment prior to moving into the home. This is now many years ago. The process was in line with the assessed needs and in line with standards at the time. There is a vacancy at the home and the admission and assessment processes will be inspected again during the second of this year’s statutory inspection. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 & 10 The residents are involved to their capacity in the decision making process and staff observe the outcome of activities and care in order to monitor and ensure a good quality of life. The care plans give good details but are in need of three monthly reviews that must be recorded in order to monitor the changing needs of residents. EVIDENCE: The assessments, histories and care plans give good information about how the service users needs are met and aspirations are addressed. The care plans have not been reviewed for some time and three monthly reviews are required. The lack of review has lead to needs not being fully addressed in a timely and planned manner or urgent action needed remained unidentified. Social, emotional and educational needs are well recognised and addressed by the care plan. All service users have a weekly plan that shows all planned activities both inside and outside the home. These showed activities to be in line with those of a healthy person of similar age. Staff provide appropriate assistance with transport and provide practical help whilst attending resource centres, shopping or places of interest. A number of areas are identified where development and learning take place. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 10 The service users are enabled by the social tutors and other staff to communicate their wishes and record outcomes of new contexts and experiences in respect of undertaken activities. Resident’s relatives and friends are involved and able to advocate on behalf of the resident. The quality of care is seen as good and one relative commented that the resident has never been better cared for in 40 years of being in care. SENSE is a service user lead organisation. People who are deaf and or blind are involved in policy development via user forums. The assessment process and care planning identify any risks and for example the resident’s ability to give consent with medication or to administer their own medication. The resident’s manual handling needs must be assessed in line with standard 9 and 18. The staff receive training during their induction in respect of confidentiality but they were aware of what must be shared with others for the protection of residents for example. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 14, 15, 16 &17 The residents are well supported in their daily routine and are offered opportunity to use and develop skills. Resident’s relatives and friends say that the visiting arrangements are very good and the support provided by staff exceeds the stated minimum standard. The meals provided are of a high quality and nutritional value and are based on the resident’s needs and tastes. EVIDENCE: The care plan and weekly plan show the ongoing and planned daily activities. This includes opportunity for learning and practicing self-help and daily living skills such as cooking and cleaning in line with the resident’s skill level. The recourse centres used provide for additional special equipment and learning opportunities. Family and friends are welcome and are encouraged to continue relationships and activities. One visitor commented that staff enable her to visit by providing transport to and from her home as otherwise visits would not be Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 12 possible. This exceeds the standard and shows good commitment to encouraging family and other relationships. The daily routine at the home is based on the assessed needs and weekly plans of residents. Resident’s can choose not to take part in any activity and records are kept showing how residents responded to new activities for example. Housekeeping tasks are incorporated in the plan in line with the resident’s skill level. The menu plan takes account of the residents likes and dislikes as well as their need. Good nutrition underpins the planning of meals and food is prepared from fresh, good quality ingredients. Staff offered resident’s options and residents enjoyed a good breakfast allowing for good taste and high nutrition with fresh fruit, yogurt and whole grain being included. Residents are involved in the food shopping that is undertaken jointly with staff. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 & 19 The health care needs of residents are well monitored and input ensured from NHS professionals were needed. The residents manual-handling needs must be assessed, recorded and any identified risk minimized. EVIDENCE: The resident’s skill level and personal signs and symbols are fully recorded and used by staff in order to communicate with the residents. New communication skills are taught during education and at the resource centre and staff practice new skills with residents in line with their weekly plan. Residents are supported with their hygiene in private and residents choose their own clothes and make as many choices as possible. The residents are subject to an annual health care assessment. Residents are registered with a local GP of their choice and consultants are involved in specialist areas. NHS staff attend to any nursing needs. Annual health care reviews are undertaken and the outcome recorded. The mobility and health needs of both service users are increasing. There is a lack of appropriate handling assessments though both service users would clearly benefit from having their needs fully assessed in line with the requirements. The staff were taking appropriate action to address the Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 14 increasing needs by ensuring a full OT assessment. However, appropriate equipment and techniques were not yet established and lead to a service user and staff being put at risk of accident or injury. Immediate requirements were made and implemented by the organisation within 24 hours in order to minimise the risk. This involved the provision of a suitable or nursing bed, appropriate training for staff in using the hoist and other equipment and ensuring appropriate instructions are given in the care plan for staff to follow. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 15 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 The complaint procedure is well published and visitors and staff know how to respond to a complaint. EVIDENCE: The organisation has a complaint procedure that is published to service users, visitors and staff. The procedure is included within the policies and service user guide for reference by residents and their representatives. The staff knew how to deal with any complaint and were aware that records must be kept. Senior managers monitor the type and number of complaints. There have been no complaints. The relative survey showed that relatives are aware of the complaint procedure. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 16 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, 29 & 30 The house provides for a homely, comfortable and clean environment that is suitable to the service users needs. Further mobility equipment must be provided and environmental restrictions considered within risk assessments. The communal space requirements are exceeded. EVIDENCE: The house is situated in Stanningley close to shops and in easy access to local shopping centres. There is a through lounge and gardens as well as a large well equipped dining kitchen. The space provided exceeds the standard for a new registration. The house is furnished to a good standard and furnishings are domestic in style and suitable to the service users needs. Communal areas are easily accessible with walking aids and wheelchairs and offer ample space. The gardens and decked patio area can be access via French doors. The current residents both have mobility needs. Both have bedrooms to the ground floor and are able to use the assisted bath situated close to the ground floor bedrooms. A hoist is available. During the inspection it was noted that for one resident a full assessment was required with regards to equipment provided and needed. Immediate action was required to provide a suitable Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 17 bed. Risk assessment must be undertaken where space, especially in bedrooms and bathrooms is limits the use of equipment. The home offers specialist aids and adaptations for the residents who have sensory impairment in line with the home’s aims. The residents had equipment and special lighting in their rooms and obviously enjoyed their use. Tactile symbols and varied textured surfaces are used. Staff and other people all have their personal symbols that help residents recognise individual staff members and other members of the organisation. Specialist computer equipment and other aids are regularly used during resource centre visits. The house was kept clean and tidy and staff were able to discuss good hygiene and how to stop any spread of infection. Visitors commented that the cleanliness of “extremely good”. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33 & 34 & 35 There were adequate numbers of staff on duty that were competent and one qualified to NVQ level 2. The manual handling training provided must be increased in order to meet the needs of the residents and to ensure the safety of both staff and residents, as high dependency in this area is apparent. EVIDENCE: The two staff on duty had been employed at the home for 6 months and 2 years. This ensured one to one staffing levels. Both had received training by the organisation with the newer member of staff having benefited from previous training and being qualified to NVQ level 2 meeting the standard for 50 qualified staff on duty. The staff files seen showed that the training needs are ascertained, recorded and addressed within the annual appraisal records held on personnel files. The level of training has been increased over time. It was noted that some areas of training are based on video training. In respect of manual handling this is not seen as adequate due to the high dependency observed by residents. All need assistance from staff with their mobility. More appropriate training must be provided to all staff. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 19 The two staff on duty were able to discuss the content of policies and procedures and were able to discuss areas of good practice showing a high level of understanding and skill in the areas of holistic and person centred care, using signs and symbols in communication, protecting vulnerable adults from abuse and risk management for example. Two personnel files were inspected in order to ensure that previous requirements had been appropriately met. The files seen included two written references, CRB clearance, and employment history, interview notes in respect of vetting future staff. This is in line with current requirements and copies of personnel files are available for all staff in the home now. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 20 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) 41 There are appropriate policies and procedures in place that staff were aware of and knew how to access. The records were accurate and up to date and gave good information. EVIDENCE: There are organisation wide policies accessible via the organisation intranet. The office is situated on the first floor and provides for a good space to keep confidential files, the computer and provide a meeting space away from the communal areas of the home. The resident’s files are fully accessible by each individual and residents are aware of their own file. Residents have recently personalised their files with textured surfaces. Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x 1 3 Standard No 11 12 13 14 15 16 17 x 3 x x 4 3 3 Standard No 31 32 33 34 35 36 Score 3 3 3 3 1 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bradford Road Score 1 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x 3 x x J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 22 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 6 Regulation 15 Requirement Care plans must be reviewed by care staff three monthly and a record kept of any changes. The service users mobility and manual handling needs must be fully assessed and a care plan completed. The registered person shall make suitable arrangments to provide a safe system of manual handling including appropriat equipment. Appripriate manual handling training must be provided to all staff. Timescale for action 01.08.05 2. 18 & 29 13 immidiate requiremen t 01.08.05 3. 29 18 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 23 Commission for Social Care Inspection Aire House Town Street 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 Bradford Road J52 S1425 Bradford Road V233883 210605 Stage 4.doc Version 1.40 Page 24 - 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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