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Inspection on 23/11/05 for 138 Bradford Road

Also see our care home review for 138 Bradford Road for more information

This inspection was carried out on 23rd November 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service users are highly dependant on staff help with many daily activities. The care plans are hence detailed in order to ensure that service users skill level is maintained and increased if possible. Good consideration is given to the service users increasing needs and ageing process. The service users are settled at the house and have a good choice of planned activities and free time. There are lots of outings to educational facilities, place of interest and holidays. All regularly go out together for a meal or to a club. Prospective service users are invited to visit the home on several occasions in order to `test` the home and facilities.

What has improved since the last inspection?

During the previous inspection requirements were made to ensure that risk assessments are undertaken for all service users with regard to their handling needs. Additionally it was required that appropriate handling equipment including a hoist be provided. All the requirements have been fully met in a timely manner. Staff and service users now benefit from safe handling techniques.

What the care home could do better:

The organisation follows a cycle of review that allows for ongoing quality assessment and improvement.

CARE HOME ADULTS 18-65 Bradford Road 138 Bradford Road Pudsey Leeds West Yorkshire LS28 6EP Lead Inspector Barbara Grell Unannounced Inspection 23rd November 2005 09:30 Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bradford Road Address 138 Bradford Road Pudsey Leeds West Yorkshire LS28 6EP 0113 239 3142 0113 2393142 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) SENSE (North) Lindsey Harwood Care Home 3 Category(ies) of Learning disability (3), Physical disability (3), registration, with number Sensory impairment (3) of places Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 21st June 2005 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 Pudsey. Bus stops are nearby. 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 flowerbeds. Grab rails and trail rails are fitted where needed. 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 DS0000001425.V272330.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced on the 23 November 2005. This is the second of two statutory inspections. In line with CSCI policy the remaining core standards were inspected and any outstanding items from the previous inspection. Reports and information on this and other social care services can be found on the Internet on www.csci.org.uk. The following methods were used. The service users were observed during breakfast and lunch as well as activities undertaken with staff. The building was seen during this process. One service user plans and case records were inspected. Staff were able to discuss policy and practice, training and supervision. The manager attended her interview at CSCI on 28 November 2005. This was the final part in the registration process and she achieved registration that day. The manager provided, as an interim measure between inspections, a selfassessment and pre-inspection questionnaire. Detailed information was provided in this process about policies, procedures, staffing levels, menu plans and so on. What the service does well: What has improved since the last inspection? Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 6 During the previous inspection requirements were made to ensure that risk assessments are undertaken for all service users with regard to their handling needs. Additionally it was required that appropriate handling equipment including a hoist be provided. All the requirements have been fully met in a timely manner. Staff and service users now benefit from safe handling techniques. 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 DS0000001425.V272330.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2&4 The assessment and introduction practices to the home are excellent and benefit service users to make informed choices and settle into their new chosen home. EVIDENCE: One example of an admission was looked at. The service user was assessed by the manager in her current situation. This service user is subject to care management support. Two care managers visited Bradford Road and an OT assessment was commissioned prior to admission to ensure that the service users individual needs could be fully met. After this process the prospective service user visited the home on two occasions and had a meal and tea and cake on the other occasion with the other service users and staff. This admission was well planned and the service user had the opportunity to ‘test’ the home prior to making the decision to move in. When the service user decided to take the place she was able to choose the colour and fittings for her bedroom. The room was fully redecorated to the service users taste prior to moving in. Observations and information is recorded during the assessment process and used to help in establishing the care plan. Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 The service user plans of the care to be provided give good and clear details and staff know how and when to assist individuals. EVIDENCE: Two care plans were inspected. Both included details of the service users level of mobility and include a manual handling risk assessment with details of how service users are to be assisted. This is in line with previous requirements and taking account of increasing needs. Care plans seen included good details of the service users skill level, dependencies and special needs. Individuals weekly and daily living plans allow for service users to be self-caring and independent when able. When dependency levels are high the actions to be taken by staff are given in clear detail. Staffing levels at the home allow for much one-to-one attention. Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13 & 17 There are excellent activities provided for that meet the service users needs and provide a high level of stimulation and fun. The meals are well prepared and enjoyed by all. EVIDENCE: Individuals have weekly plans showing planned and ongoing activities. This includes educational opportunities as well as a variety of social activities and outings. The home has a minibus that is suitable to take individuals or the group out to places of interest. There are an excellent variety of activities and choices provided. Service users had two short breaks away on holiday this year. On the day of inspection one service user went out during the morning. Two enjoyed activities in the home in the morning and went out in the afternoon. Service users take a full part in community life and use and visit the local shops and hairdresser for example. Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 11 The meals at the house are prepared by staff from fresh ingredient. The service users dietary needs are considered and inform the menu plan. Individual tastes are well known to staff. Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Service users are appropriately supported with their mobility and handling needs. EVIDENCE: Moving and handling techniques have now improved to a good standard and appropriate equipment was promptly provided after the previous inspection. Records gave clear details of assessments undertaken and practice were in line with the care plans. Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 13 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): 23 Service users are protected by the homes policies and these are known to staff. EVIDENCE: The organisation has sound adult protection policies and staff receive training during their induction. All were able to discuss how they would act in case of any suspected abuse or allegations. A check is undertaken of the staff’s suitability to work with vulnerable adults (POVA). Any extreme behaviour is assessed and any known triggers minimised. Programmes are individual and in line with current good practice. Clear records are kept of service users income and expenditure. Service users are unable to handle their own finances and have to be fully assisted by staff. Any savings are held in interest paying bank accounts. Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 14 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): 29 The individual and collective handling needs are assessed and appropriate equipment provided. EVIDENCE: Appropriate handling equipment is now in place in line with requirements. A hoist and appropriate handling slings have been provided. Good practices are now apparent and an OT assessment was undertaken to ensure that the individual needs of the newest admission could be fully met. Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 15 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): Standards not assessed on this occasion. EVIDENCE: Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 16 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): 39 & 42 Quality assurance and safety systems including training ensures that service users receive a safe and quality service. EVIDENCE: The manager and staff are involved in undertaking quality checks in all areas. The management make annual plans for the upgrade and upkeep of the building, fixtures and fitting. The organisation also plans and budgets for staff training, appraisal and development. The views of family and friends are clearly sought and feedback from the previous inspection confirmed this. The registered manager has undertaken an assessment against the minimum standards and this showed no shortfalls. Service users are not able to comment verbally in two cases but do have signs and behaviours that show anger or discomfort. Safety aspects are regularly checked and monitored. Some are visually monitored by staff other areas such as fire systems, wiring and clinical waste Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 17 are attended to by contractors. An accident and fire alarm testing records are completed by staff. The service users would be reliant on staff help in any emergency. This level of dependency is reflected in the staffing levels provided. Staff confirmed that they received training in all aspects of safety during their induction training and that refresher training is provided. Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 18 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 X 3 X 4 X Standard No 22 23 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bradford Road Score 3 X X X Standard No 37 38 39 40 41 42 43 Score X X 3 X X 3 X DS0000001425.V272330.R01.S.doc Version 5.0 Page 19 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 Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 20 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. Extracts may not be used or reproduced without the express permission of CSCI Bradford Road DS0000001425.V272330.R01.S.doc Version 5.0 Page 21 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!