Inspection on 18/04/07 for Bramley Gardens

This inspection was carried out on 18th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bramley Gardens 07/02/06

Bramley Gardens 20/06/05

Bramley Gardens 08/02/05

Bramley Gardens 13/07/04

Bramley Gardens 10/02/04

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 Bramley Gardens Skelton Lane Leeds West Yorkshire LS14 1AE Lead Inspector Dawn Navesey Unannounced Inspection 18th April 2007 09:00 Bramley Gardens DS0000001426.V335309.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 Bramley Gardens DS0000001426.V335309.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. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Bramley Gardens Address Skelton Lane Leeds West Yorkshire LS14 1AE 0113 273 3771 0113 2323872 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.hft.org.uk Home Farm Trust Care Home 34 Category(ies) of Learning disability (30), Physical disability (4) registration, with number of places Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th February 2006 Brief Description of the Service: Bramley Gardens is made up of a collection of two storey houses, some divided into flats, and clustered together on the same site on the edge of the Whinmoor area of Leeds. The houses are built around a spacious landscaped central courtyard garden. Each property has its own garden and the whole area is surrounded by green fields. The nearest shops and pub are about five minutes walk away and a half hourly bus service into the city centre and Wetherby passes the entrance. The home is currently a little isolated from the local facilities. Each house is equipped, staffed and occupied according to the assessed needs of the service users. The home has an overall scheme manager, responsible for all the organisation’s services in the Leeds area,and an assistant manager who will be the registered manager. Unit managers are responsible for specific groups of houses and a team of care workers who have different levels of experience. A day centre, on the same site, but separated from the houses, provides day services. This is coordinated by a day services manager. The home has a main administration office and three vehicles to assist with transport. Service users are encouraged to make choices and decisions about how they wish to conduct their own lives and receive support to enable them to be involved in all aspects of daily living. There is a wide programme of social, educational and recreational activities. Funding for care is assessed on an individual basis. The current scale of charges is £651-43 to £1446-87 per week. Additional charges are made for magazines, papers, holidays, hairdressing, leisure activities and taxis. Bramley Gardens DS0000001426.V335309.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 One inspector between 9am and 5-10pm carried out this unannounced inspection. The purpose of this inspection was to make sure the home was providing a good standard of care for the people living there. The people who live at the home prefer the term service user; therefore this will be used throughout the report. The methods used at this inspection included looking at care records, observing working practices and talking with service users and staff. Information gained from a pre-inspection questionnaire and the home’s service history records were also used. Before the visit, survey cards were sent out to service users, relatives and visiting professionals to the home. Three of these have been returned and this information has also been used in the preparation of this report. There were no visitors to the home on the day of the visit. Feedback was given to the manager at the end of the visit. Thank you to everyone for the pre-inspection information, returned survey cards and for the hospitality and assistance on the day of the visit. Requirements and recommendations made during this visit can be found at the end of the report. What the service does well: Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 6 Staff have a very good knowledge of service user’s needs and respond well to them. The atmosphere in the home is warm, friendly and welcoming. Staff interact well with service users and treat them as individuals. They assist service users with their independence and make sure they are treated with dignity and respect. The detailed support plans make sure that all service users’ needs are fully met. One person said, “I like it here”, another said “It’s alright here”. Staff make sure that service users have regular and varied activity, which includes college courses and paid employment for service users. A relative who returned a survey said, “They’re always doing things with everyone and try to get everyone involved.” A service user said, “I always have plenty to do”. Staff are also good at encouraging family involvement and supporting service users to keep in touch with family and friends. A relative who returned a survey said, “In the main, we have found that all staff are kind and always have time for relatives and communicate with us in a warm and friendly manner.” The organisation has produced accessible information on the home and its policies, by using easy words and pictures. There are good adult protection and complaints procedures. Staff are aware of what to do if they observe poor practice. A relative who returned a survey said, “Complaints are always dealt with immediately”. Service users receive a good standard of health care. The staff team work well with the health professionals involved with service users. Staff receive a good standard of training. There is a commitment to NVQ (National Vocational Training). Over half of the staff team have gained this qualification and the others are working towards it. The managers have good leadership skills and are supportive to the service users and the staff team. Staff made comments such as “She gets involved and has lots of good new ideas”. What has improved since the last inspection? Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 7 The managers now write to relatives to tell them when a CSCI inspection has taken place. They also tell them how to obtain a copy of the report and that this is also available on the internet. The new support plan documentation is person centred and uses easy words, symbols and pictures. This makes it more accessible to all. Weekend activity has increased for service users. Staff make sure a weekly courtesy call is given to service users’ families if they want this. This helps service users to keep in touch. Lunch time meals are now more varied. The assistant manager works some evenings and weekends to give an increased management presence at these times. 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. The summary of this inspection report can be made available in other formats on request. Bramley Gardens DS0000001426.V335309.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 Bramley Gardens DS0000001426.V335309.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 and 5 People who use the service experience excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Written and verbal information available to service users who may use the home is comprehensive and provides enough information for service users to decide whether the home will meet their needs. Also, service users and their carers can be sure that the home will meet their needs following assessment for admission. EVIDENCE: The Statement Of Purpose and Service User Guide have been produced in an easy read format, using large print, symbols and photographs. These are both kept on display on various notice boards around the service. Each service user also has their own copy of the Service User Guide and a charter of rights which explains how to use the complaints procedure. The manager is currently looking at computer programmes that could be used to provide a speaking Service User Guide for service users who do not find the paper copy useful. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 10 CSCI inspection reports are made available to service users and relatives. All relatives are written to when an inspection report is available. They are told that a copy can be obtained from the service or that copies are available on the internet. The manager requested easy read summaries from this inspection, for all service users and said that staff would go through them with individuals. Service users have a contract with the organisation that outlines all the terms and conditions and gives service users information on their benefit entitlements. Some of the contracts had not, however, been updated or reviewed to include the current costs of the placement. The manager said she would make sure this was done for everyone. Service users’ needs have been assessed to make sure the home could meet their needs. An assessment of the most recently admitted service user was seen. It was clear that this assessment had been done properly, involving the service user and their family. Visits had been offered and care management assessments had been obtained prior to the service user moving in. The service is currently introducing a new assessment document that will be used for new and current service users as a basis for support planning. This means that all current service users are having their needs re-assessed to make sure they are being given the right support. This is good practice. Service users, who were able to, spoke highly of the service and said they had made a good decision in choosing this service. One person said, “I like it here”, another said “It’s alright here”. Bramley Gardens DS0000001426.V335309.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 excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Support plans and risk assessments provide clear detailed instruction on how service users’ needs are to be met. It is clear that service users or their relatives are involved in this process and the day to day running of the home. EVIDENCE: Service users’ support plans are detailed and give specific instruction to staff on care and support needs. It is pleasing to see that the plans are very individual and person centred, focussing on people’s strengths and personal preferences. They are often written in the first person and a variety of styles is used, such as goal planning and essential lifestyle planning. Staff have a Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 12 good knowledge of service users’ needs. They were able to accurately describe the care they give and talk about the detail of how service users like to be supported in their daily routines. Staff said they had received training in care planning, risk assessment and person centred planning. The manager said that a person centred planning co-ordinator had now been employed by the organisation and that more staff from the service would now be trained up as person centred planning facilitators. All support plans have been regularly evaluated and reviewed, with changes being made as needed. Person centred planning meetings have been held which involve the service user, their family if they wished, staff and other professionals involved in their lives. Goals had then been set at the meetings for service users and staff to work towards. There are clear plans in place showing how goals and future aspirations are to be achieved. Risk assessments are linked to the support plans. Staff and the manager have a good attitude to risk taking. Service users’ safety and rights are maintained while independence is encouraged. Where risk assessments have highlighted a need for additional staff support, this has been done to ensure safety for all. Risk assessments are up to date and reviewed. As mentioned in the Choice of Home section, the organisation is currently introducing a new way of assessment and support planning. This will be a computerised system called Support Planning and Recording System. (SPARS). This new document will cover all aspects of service users’ lives and detail all their support requirements in a person centred way. Service users and their relatives are involved in this process. The document has been produced in an easy read and picture format to make it more accessible to all. Staff are currently being trained in the use of this new system. They spoke positively of its use and the training they have received. Staff showed a good awareness of the support plans and risk assessments. One staff member explained how staff became familiar with these during their induction. Another staff member said they had found the care plans useful when they first started working at the service. Relief and agency staff are also aware of the plans and could talk about individual’s support needs. Service users were offered choices throughout the day, for example, what to do, where to go and what to eat. Staff respected service users’ choices and responded well to their requests. Meetings are held every three months in each unit for the families of service users. This makes sure they can comment on the service provided and can also meet up and share experiences with other relatives. Relatives are also sent an annual satisfaction questionnaire from the service. Service users do not have a regular meeting. However, the new manager is currently looking at setting up some “speaking out” groups within the service. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 13 The organisation is also working with a local advocacy service to look at practical ways of further involving service users who do not use verbal communication to be able to “have a say”. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 14 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 excellent 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 ranges from college courses, paid employment, art classes, job clubs, horse riding, swimming, bike riding, computer courses, shopping, meals out, gardening and canoeing. Each service user has an individual plan of activity that matches their interests. The day centre that is on the same site as the service has a Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 15 Community Inclusion Team who have been looking at ways to extend the variety of activity at weekends for those service users who stay within the service. Staff said this is working well, with many of the activities such as canoeing now taking place at weekends. A relative who returned a survey said, “They’re always doing things with everyone and try to get everyone involved.” A service user said, “I always have plenty to do”. On the day of the visit, many of the service users went out on college courses or other community activities such as swimming. Service users’ support plans have plenty of detail on their likes, dislikes and interests. Staff are good at suggesting new things to try, especially for service users who cannot make choices easily due to their lack of verbal communication and complex needs. Service users are encouraged to meet up with old friends and to keep in contact with their families. A relative who returned a survey said, “I always get a courtesy call through the week.” Staff said that service users are known in the local community and use all local facilities such as shops and pubs. Some service users attend a local church. The service has a variety of transport options for service users, including a mini-bus adapted for wheelchair users. Staff said they also use public transport and have been successful in campaigning for a wheelchair accessible bus to be put on the local route. They are now campaigning for a bus shelter to be put at their nearest bus stop. Staff support people with cultural aspects of their lives. A service user who follows the Jewish faith is supported with a kosher diet and staff have put a list of Jewish festivals at the front of their personal file. A service user who is vegetarian is supported with diet. Staff are flexible in meeting the diverse and changing needs of service users. A service user who is exploring different religions such as Christianity and Buddhism is respected in his choices. One staff member said he is arranging a trip to Lourdes for a service user who is Catholic. Staff were seen to support people with courtesy and thought for their dignity. Staff said it was important to make sure service users are as independent as possible. They said they are encouraged to get involved in household tasks and to make drinks and snacks for themselves. Some service users have their own house within the service and prepare all their own meals with some staff support. This helps to prepare service users who may wish to move on to more independent living. There was plenty of social interaction between the staff and service users. The atmosphere was happy and relaxed. Menus appear to be well balanced and nutritious. Choices are made on a daily basis from what is available in each unit. Service users are involved in doing the weekly shop and this is based on their likes and dislikes, which means there is usually always something available that service users like. However, if a service user wants something different to what is on the menu, this can be done. A good variety of food is available and staff make sure there is a good Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 16 selection of fresh produce available. The main meal of the day is eaten at teatime. Staff make sure there are a variety of lunches on offer. Service users can help themselves to snacks and drinks throughout the day. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 17 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. Personal and health care support is provided in a way that meets service users needs. However, service users are not fully protected by the home’s policies and procedures for dealing with medicines but the manager has agreed to remedy this. EVIDENCE: Staff support service users 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 that service users’ needs are fully met. Staff have good knowledge of their likes, dislikes and preferences. A relative who returned a survey said, “Support and care needs can be hard to meet when there are staff shortages due to illness or staff leave and are not Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 18 immediately replaced.” All agency and relief staff spoken to had good knowledge of service users’ personal care needs. The manager has also introduced a handover procedure for agency and relief staff. This makes sure that all personal care information is read and understood before they commence work with service users. She also makes sure that agency and relief staff work alongside a regular staff member to get to know the personal care needs of service users. An agency worker spoken to described this induction process that he had gone through. The support plans also have details of any health professionals that service users see. These include, GP, speech and language therapist, dentist, specialist nurse, psychologist and chiropodist. Records are kept of any health appointments or telephone calls and their outcome. Health action plans have been completed with service users. They are person centred and include important information such as medical history. Staff accompany service users on their appointments. This includes appointments that are held with specialists in various parts of the country. Some service users are supported to attend appointments in private if they wish. Some service users have specialist health needs. These include epilepsy and mental health needs. Staff have received training in these issues. The manager said that any specialist training needs that arise will be addressed through local training providers or the organisation’s training department. An example of this is dementia awareness. Service users’ emotional well being is seen as important. Bereavement counselling is currently being arranged with a local charity. The home uses a monitored dosage pre-packed system for medicines. All staff take responsibility for the administration of medication and have been trained to do so. There are good ordering and checking systems in place, with a clear audit trail for any unused medication returned to the pharmacy. The medication administration record (MAR) sheets were checked and showed no errors in administration. However, the current practice of “potting up” the medication prior to its administration must cease. The pre-packed system is designed to be used to administer medication from the packs to each person individually. Putting the medication into pots with service users initials on the top and leaving them in the medication cupboard for other staff to dispense is not safe practice. Errors in administration could be made. The manager said she would change this system and the local guidelines to reflect the guidance of the Royal Pharmaceutical Society with regard to medication administration. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 19 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 excellent quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Service users and their relatives have their views listened to, taken seriously and acted upon. There are good systems in place to protect service users from abuse and to make sure poor practice is reported and dealt with. EVIDENCE: The home has a complaints procedure displayed on notice boards around the service and each service user is given their own copy. All those who returned a survey said they knew how to complain. An accessible complaints procedure called “Making Things Better” has been produced. This is in an easy words and pictorial format, to make it is more accessible to all. Service users, who were able to, said they knew how to complain and talked of the complaints form they would use. One service user said they had used the form and were satisfied with the response they got. Any complaints the home has received have been dealt with, recorded and investigated properly. A relative who returned a survey said, “Complaints are always dealt with immediately”. The manager said there are often things that can be improved after complaints are raised. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 20 Staff have received training on safeguarding adults. They were able to say what action they would take if they suspected abuse or had an allegation of abuse made to them. They were also able to describe the different types of abuse. A service user said they had been supported to report concerns to the police. The organisation has a detailed policy on the protection of vulnerable adults and reporting concerns. There have been a number of safeguarding adult issues recently within the service. These have been dealt with promptly and thoroughly investigated. Proper action has been taken and the appropriate organisations informed in order to protect service users. The service has a policy that no physical restraint is used. During the visit, an incident was observed and staff defused the situation without the need for any restraint. They were very clear that this is the policy and practice. Good records are kept of service users’ finances and their monies are kept safe. Proper handovers of the monies takes place at each shift change and the manager regularly checks the finance records and receipts. Good systems have been put in place to give service users independence skills with their finances and bank accounts while at the same time protecting the safety of it. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 21 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): 24,29 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 offers a homely, clean, safe environment for service users and provides appropriate specialist equipment. EVIDENCE: The communal areas and some bedrooms of houses 1a, 2, 5 and 8 were seen during this visit. In the main, the houses are clean, fresh and homely looking. Some coffee tables and dining room tables are looking a bit worn and in need of re-varnishing or replacement. The bathrooms and toilets in house 2 are in need of some redecoration and repair to the bath panel. The manager and staff are aware of this and said they are due for redecoration in this years Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 22 programme. The kitchen in 1a is also due for renewal this year. The service has a rolling programme of refurbishment and redecoration. There is also a full time maintenance officer at the service. House 8 is well equipped with specialist equipment that fully meets the needs of the service users. This includes, mobile hoists, ceiling tracking hoists and specialist seating. Some bedrooms also have en-suite bathroom and toilet facilities. All bedrooms seen have been personalised and made individual to the service user. A service user who has a visual impairment has had the room decorated in contrasting colours to make the best use of his vision. The service has a large attractive enclosed garden. Some service users are interested in keeping a garden area and have been supported by staff to do this. The paths are wheelchair accessible, which gives service users some independence to go into the garden on their own. Clinical waste is properly managed and staff wear protective clothing when attending to service users’ personal care needs. Staff have received training in infection control and were able to say what infection control measures are in place. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 23 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): 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 service users. Service users are protected by the home’s recruitment procedures. EVIDENCE: Each of the houses on the site has a unit manager who leads a team of support workers. The unit managers report to the assistant service manager and service manager who are both based on site. There are staff on duty throughout the day and night. The numbers of staff on duty are based on the needs of service users in each house. On the day of the visit, there were sufficient staff on duty in all the houses visited. The assistant manager works mainly Monday to Friday but has recently started to work some evenings and an occasional weekend in order to have a more rounded view of the service and needs. A relative who returned a survey said of staff, “They are individuals with their own strengths and weaknesses. Some are very good. In Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 24 the main, we have found that all staff are kind and always have time for relatives and communicate with us in a warm and friendly manner.” It is clear that extra funding is sought for additional staffing for service users who have behaviours that may challenge others. Staff spoke of a recent staffing increase of one to one hours for a service user. They said this had alleviated problems from occurring at busy times when this service user was unoccupied. Recruitment is properly managed by the home; interviews are held, references and CRB (Criminal Record Bureau) checks are obtained before staff start work and checks are made to make sure staff are eligible for work. Service users are involved in the recruitment of staff. This is good practice. The manager has worked with the managers of agencies they use to supply agency staff to make sure they have a regular bank of agency staff to try and ensure consistency for service users. Staff’s training is well managed. Good records are kept of staff’s training and when their updates are due. The manager assesses this regularly to make sure training doesn’t get missed. The organisation has introduced the Skills for Care Common Induction Standards for new staff. Staff spoke highly of their training and the support they get from the manager. One staff member said she felt the excellent training she had received had helped her promotion. The manager is aware of the training updates that are needed and has nominated staff for training courses in the near future. There is an annual training plan provided by the organisation. This is comprehensive and covers all the training needs of the staff. Training needs are identified through an appraisal system and based on the needs of the service users. Over 50 of the staff team have achieved an NVQ (National Vocational Qualification) in level 2 or above. Staff said they felt more knowledgeable and confident within their role since undertaking the NVQ. Many others in the staff team are also currently working on their NVQ. All staff said they felt they had a good team and the manager was very approachable and supportive. Staff made comments that included, “She is like a breath of fresh air”, “She gets involved and has lots of good new ideas”. Staff said they felt communication and teamwork within the home were great. Regular staff meetings take place. Staff receive regular supervision and said they find this useful. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 25 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): 37,38,39 and 42 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 service users are seen as important to the managers and staff and are safeguarded at all times. EVIDENCE: The home has an experienced manager who has completed her NVQ level 4 and Registered Managers Award. She came into this post in August 2006. She works alongside staff to make sure of good practice and has administration time to complete her management tasks. She offers good Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 26 leadership to the staff and has good systems in place to make sure service users are supported and cared for properly. The overall Leeds Services Manager who is based in the same office supports her. Since joining the organisation, she has undertaken further management training courses such as investigation skills and disciplinary and grievance training. She is also due to do the training to become a person centred planning facilitator. She has her interview with the CSCI arranged for May 2007 to become the registered manager. The manager carries out regulation 26 visits in the service on a monthly basis. This involves talking to service users and staff about the service. A report of these visits is made showing details of any action to be taken to improve the service. Also, each unit manager completes a monthly quality audit of support plans in a house where they are not the manager. This is good practice. In addition to this, the organisation carries out annual and quarterly service reviews, as part of its quality assurance programme. This also includes service users, relatives, care managers, and staff. A report from these reviews is sent to relatives and made available in the home. Comments the organisation has received on the quality of the service from relatives were very positive. The manager said they are now looking to introduce quality checkers. This would mean that service users would assist with service reviews, interviewing other service users and staff. Staff carry out weekly or monthly health and safety checks around the home such as fire alarms, emergency lighting, water temperatures and checks on the house vehicle. Maintenance records are well kept. Environmental risk assessments are completed and reviewed. Health and safety training is well maintained. Accident or incident reports are completed. However, there is no section for follow up action to be taken after any accident or incident and the manager does not have a system in place where she can analyse accidents to see if there are patterns, trends or ways of avoiding future accidents. She said she would develop a system to address this. The home has a comprehensive range of policies and procedures in place to ensure health and safety. The procedures are all in a staff handbook and on the organisation’s intranet for staff to access easily. Each of the houses has a computer. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 27 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 4 2 4 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 3 30 3 STAFFING Standard No Score 31 X 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 4 3 X LIFESTYLES Standard No Score 11 4 12 4 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 3 3 X X 3 X Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 28 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 YA20 Regulation 13.2 Requirement The manager must make sure that current practice of “potting up” the medication prior to its administration is stopped as this could lead to errors in the administration of medication. Timescale for action 30/05/07 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 YA42 Good Practice Recommendations The manager should consider developing a system where she can analyse accidents to see if there are patterns, trends or ways of avoiding future accidents. Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 29 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 Bramley Gardens DS0000001426.V335309.R01.S.doc Version 5.2 Page 30 - 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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