Inspection on 20/06/05 for Bramley Gardens

This inspection was carried out on 20th June 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 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 18/04/07

Bramley Gardens 07/02/06

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 Sue Dunn Unannounced 20 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. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Bramley Gardens Address Skelton Lane, Leeds, West Yorkshire, LS14 1AE 0113 273 3771 0113 2018447 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) Home Farm Trust Mrs Sandra Farrell Care Home 34 Category(ies) of Learning disability (30), Physical disability (4) registration, with number of places Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 08/02/05 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. Each property has it’s 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 residents. The home has an overall scheme manager, and a registered manager. Unit managers are responsible for specific groups of houses and a team of care workers who have different levels of experience. All staff new to the organisation have to complete a full induction programme followed by ongoing training which includes NVQ. 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 uses 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. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector undertook the inspection, which was unannounced. The inspection started at 12md and finished at 4.45pm. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents. An acting unit manager and the administrator assisted with the inspection, as the manager was unavailable. The operations manager who is temporarily managing the home in the manager’s absence made a brief visit to the home during the inspection The inspection included observation of and discussion with some residents, a visit to three of the houses, discussion with staff, examination of a selection of records including care plans and a recruitment file. What the service does well: What has improved since the last inspection? One person has taken responsibility for re-organising the care files and there was marked improvement since the last inspection. The files were orderly and consistent in format making it easy to find information. The cross checking of files by each of the unit managers for the purpose of quality and consistency has provided an effective monitoring system There was evidence of the involvement of other professionals in the care management process. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 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 Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 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. The Home provides a satisfactory information pack about the services and facilities it can provide. EVIDENCE: The statement of purpose and service user guide seen on previous inspections give a good guide, in a pictorial and symbol format, which assisted people with limited communication skills, to understand what the home provides Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 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 The care files were well ordered and provided a good chronological record of the care being provided in a manner which made it easy to cross reference information. Residents were assisted to make choices about their lives and those who were able to communicate verbally were able to talk about their care plans. EVIDENCE: One member of staff was given the task of re-organising the care files after the last inspection. The Care files inspected all used the same layout, which made it easy to find information in each section of the file. The unit managers use a checklist for cross checking the files in the houses of their colleagues each month. The comments on the check lists showed that this system is helping the staff to pick up any shortfalls in the way information is recorded. The Health care records were easy to follow and one of the residents said that after a recent visit to the consultant he was very pleased to be told he could come off all his medication. Another file included a risk assessment, the result of which led to the fitting of a new gate with a digital locking system. Daily recording in most care plans seen gave a good picture of daily events. Some staff were better than others at recording their own actions in response Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 10 to situations. There appeared to be some confusion about where to record ongoing progress of goals as some staff were recording this on the care plan rather than the daily progress notes. The unit manager acknowledged that there had been communication difficulties in the past with the way staff worked with other professionals involved in residents’ care but the felt this had improved. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 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) 11,12,15,17 Educational, social and recreational activities provide a good balance and allow the opportunity for personal development. Efforts should be made to encourage a wider choice of healthy eating food at lunchtime. EVIDENCE: Information in the holiday file showed that one person was going abroad on holiday. Another person said he was hoping to go away for the weekend to a motoring event. Other residents were at the day centre, relaxing at home and one was going to do voluntary work in a charity shop. Residents all now have lunch in their own homes. One person said he was not happy about the closure of the day centre canteen for lunches as he enjoyed being able to meet up with other people at lunchtime. All the people having lunch at home appeared to be having sandwiches. A member of staff in one house said they were aware of this and tried to buy various types of bread. However there was no evidence of this seen. The main meal of the day is in the evening. Residents are assisted to make their meals according to their abilities. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 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 standard(s) 18,19, Overall, the care files gave a good indication of the level of care each person received. The staff in some houses need more support in understanding what information is relevant to record. EVIDENCE: The layout of the care files makes it easier to see how goals are being agreed. One file showed that the staff had been given guidance by the Community Psychiatric Nurse to formulate a care plan for a person moving towards a more independent lifestyle. It was good to see that the goals for one person had been developed in pictures so that he could refer to them. The daily log of events in each person’s life did not indicate if staff were referring back to how this fitted in with the progress of the goals. One person said after his latest visit to London the doctor was very pleased with his progress. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 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 standard(s) 23 The home has a robust adult protection procedure and all staff have been trained to understand the subtle aspects of abusive behaviour. EVIDENCE: The Home Farm Trust trainer provided in house training for all staff on Adult Protection earlier in the year. A member of staff spoken with was able to describe the action to be taken in the event of any concerns. The home has, in the past, handled any allegations of suspected abuse or inappropriate behaviour in a professional way and in accordance with procedures. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 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 standard(s) 24,25,28,30 The home provides safe and comfortable ‘domestic’ style housing. Improvements and redecoration are funded from the annual budget, however, staff should be mindful of the details that ensure the furnishings and fittings in each house are up to an acceptable standard. EVIDENCE: The communal areas of three houses (2, 8 and 9) and one bedroom were seen during this visit. Some residents were at home and using the communal areas for relaxation. Another person was gardening with a member of staff. Houses 2 and 8 were clean and fresh. In house 8 curtains were loose from the rails and the stair carpet looked grubby. This lack of attention to detail let down the overall impression of the house. The home has a rolling programme of refurbishment and decoration. New gates and a digital locking device have been fitted to the enclosed central garden to reduce an area of risk for one person without restricting the freedom of movement of more able residents. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,36 The number of staff available on the late shift was sufficient for the number of residents. However, staff shortages, for any reason, must not be allowed to create a situation which deviates from care plans. An NVQ programme, formal supervision and routine training updates allow staff to develop their skills and knowledge. The home has a sound recruitment and selection process. EVIDENCE: The Leeds scheme manager said that the overall staffing was good with most of the posts filled. One member of staff expressed the view that there were not enough staff as an agency worker was to assist on the late shift. Twelve staff were shown on the rota for the late shift but of this number only one person was rota’d to work in house 2. A behavioural plan showed that staff in this house must not work alone. The situation was said to have arisen as the result of a mistake on the rota and the staff in an adjoining house would be providing any necessary back up support. A longstanding member of staff confirmed that she has regular updated training. Another member of staff in employment for a year is working towards the NVQ2 award. She was observed to reply to a resident’s request in a very clear and patient manner. A member of staff confirmed that all staff receive regular supervision, which includes an examination and discussion of a selection of care files. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 16 The recruitment and selection file for a recently interviewee showed a wellcompleted application form and a clear record of the interview. The candidate is to be appointed once a satisfactory CRB check is received. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37,38,40,41,42 The management structure offers staff the opportunity to develop skills and maintain supportive relationships for residents. The health safety and welfare of residents is safeguarded without unnecessary restrictions EVIDENCE: The registered manager of the home was on long-term sick leave at the time of the inspection. Her line manager has overall management responsibility for the home during her absence. This, it was said, requires senior staff in the home to be more responsible and accountable for their actions. The acting house manager of house 2 was responsible for the home at the time of the inspection. One manager was on holiday with some residents, one was on a training course and one was on long term sick leave. The fire training records were checked and with the exception of the staff in houses 7 and 9, who have a further training session booked, all have had training since February of this year. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 18 Care files showed risk assessments had been carried out and action taken to reduce risks, as seen by the new security gate. Risk management plans are designed to promote independence rather than impose undue restrictions to peoples’ lifestyles. There had been a marked improvement in the personal records since the last inspection. Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 19 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 x x x x Standard No 22 23 ENVIRONMENT Score x 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 x x 3 x 3 Standard No 31 32 33 34 35 36 Score 3 3 2 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bramley Gardens Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 3 3 x 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 20 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 OP33 Regulation 18 Requirement The number of staff rotad to work in each house on any shift must take account of the care planning for the residents in that house Timescale for action 31.07.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard OP6,OP18 OP17 OP28 Good Practice Recommendations Staff should be given more support in recording of information about the way care is given and goal planning progresses Efforts should be made to encourage residents to make healthy eating choices at lunchtime Staff should have regard to the details which ensure funishings and fittings are of a satisfactory standard Bramley Gardens 20060616 J52 S1426 Bramley Gardens V182853 Stage 4.doc Version 1.30 Page 21 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. 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