Inspection on 21/11/06 for Broad Lane

This inspection was carried out on 21st November 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

Broad Lane 22/12/08

Broad Lane 27/02/06

Broad Lane 06/10/05

Broad Lane 19/10/04

Broad Lane 15/04/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Broad Lane 199 Broad Lane Bramley Leeds West Yorkshire LS13 2NJ Lead Inspector Sue Dunn Key Unannounced Inspection 21st November 2006 12:15 Broad Lane DS0000001428.V310910.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 Broad Lane DS0000001428.V310910.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. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Broad Lane Address 199 Broad Lane Bramley Leeds West Yorkshire LS13 2NJ 0113 255 8659 0113 2558659 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.c-i-c.co.uk. Community Integrated Care Doreen Holmes (applying for registration) Care Home 5 Category(ies) of Learning disability (2), Learning disability over registration, with number 65 years of age (3) of places Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 27th February 2006 Brief Description of the Service: Community Integrated Care, a registered charity, provides the care and services at the home whilst South Yorkshire Housing Association owns the property. The care home provides personal care and support to five ladies with learning disabilities. The home is a single storey building; bedrooms are single occupancy, with shared facilities in the lounge and dining room. The house is surrounded by gardens, and is situated in Bramley, a suburb of Leeds. Nearby is a large shopping and leisure complex with a wide range of amenities regularly used by the ladies. The home has its own mini bus that enables the ladies to participate fully in community life. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the inspection visit was to ensure the home was operating and being managed for the benefit and well being of the service users. One inspector undertook the inspection, which was unannounced. The inspection started at 12.15 pm and finished at 4.25 pm. A pre inspection questionnaire had been completed and returned by the manager and was used to support judgements made during the inspection visit. The report is based on accumulated information about the home since the last inspection in February 2006, observation and conversation with service users, staff and a visitor, examination of documentation including 2 care files (which were tracked), and an inspection of the premises. The weekly fees range from £999.61 - £1031.71 The services not included in the fee are hairdressing, personal clothing and toiletries, social activities, holidays and transport. A manager, who has not yet been registered, has been appointed since the last inspection. There were no outstanding requirements from the last inspection report. The inspector would like to thank the ladies living in the house and the staff for their assistance and comments during the inspection visit. What the service does well: The Statement of Purpose is a very concise, informative document that describes what the home set out to do and how it achieves its aims. The ladies living in the house are consulted about all matters which affect them including their views about new housemates. Care files were of an excellent standard with sufficient detailed information from the ladies to give any member of staff guidance on their lifestyle and care preferences. Regular consultation with individual support workers allowed achievements to be reviewed and new plans to be made to ensure each person led a fulfilling lifestyle. There was a full and varied programme of tasks and activities tailored to group and individual tastes and interests. Health care needs were closely monitored and professional advice and equipment obtained as needs changed. Staff had a good knowledge of each of the ladies. This included agency staff who work in the home on a regular basis. There was a commitment to training and good practice. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 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 Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 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): 1, 2, 3 and 4 Quality in this outcome area was good. The judgement was based on all the available evidence including information provided by the manager before the inspection, discussion with the senior support worker and examination of documentation. The Statement of Purpose was updated and gave a clear picture of what the home set out to do and how it went about it. The ladies in the home were consulted about the suitability of new admissions. EVIDENCE: The Statement of Purpose had been updated and proved to be a very concise, informative document which described what the home set out to do and how it achieved its aims. The brochure was set out in pictorial form for the benefit of service users. This is being updated by the manager with the help of the ladies. The Statement of purpose described the admission process, which included assessments of need and a series of introductory visits to the home. The ladies living in the house were involved in decisions about the suitability of people to be admitted. There had been no admissions since the last inspection. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 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, 7, 8, 9 and 10 Quality outcomes in this area were excellent. This judgement was based on all the available evidence, which included speaking to staff, examining two care files and speaking to service users. Documentation was clear, detailed and guidance on care was directed by the preferences and wishes of the ladies themselves. Risk management plans were aimed at reducing areas of risk without undue restriction of rights. EVIDENCE: Two care files were examined and tracked These were written in the first person and gave clear guidance to staff on how each person wished to be supported. Risk assessments were based on daily activities and were relevant to lifestyle and ability. Risks were identified and were followed by an action plan which could be followed through in each person’s Health Log. Monthly care planning updates were excellent giving a list of achievable goals for each month and a recap of the progress of the previous months goals. The information was in a simple format that was easy to follow and showed that the ladies had been supported to achieve their aims. Individual daily diaries in hard- back form provided a record of each person’s active lifestyle Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 10 A workbook, also written in the first person gave each lady the opportunity to write about her life, achievements and friendships to date. A part of each book respected rights to confidentiality and could only be read with the permission of the person concerned. One person’s plan to move was a source of frustration, as it was taking longer than expected to find a house. There could have been more recorded in the file to show the progress and planning for this which was said by staff to be in the early stages. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 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 the following standard(s): 11, 12, 14, 15, 16 and 17 Quality outcomes in this area were excellent. This judgement was based on all the available evidence, which included examination of documentation, discussion with the ladies, staff and a visitor and observation. The ladies were supported to lead lifestyles which matched their personal preferences and interests. Staff should try to serve soft diets in a way which allows the person eating the food to distinguish between the flavours on the plate. EVIDENCE: A calendar of each person’s weekly social and recreational programme was seen on the office wall. It was clear from reading the information written in daily diaries that though the ladies had weekly routines they were free to choose on a day-to-day basis and there were sufficient staff on duty to allow this to happen. On the day of the visit one person was out at a day centre. The others were having a light lunch after a mornings shopping with the assistance of a service users from another home. Two ladies went out to a drama workshop in the afternoon and a musical entertainer visited later in the day when all the ladies Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 12 were at home. He had been visiting the home since it opened and spoke highly of the home, the staff and the ladies quality of life. One lady said she attended a disability group forum at Leeds University and the ladies spoke of a recent weekend break in Blackpool. The house has a mini bus but as only one support worker can drive the bus his rota is organised to fit in with planned activities which required transport. A part time housekeeper/driver has recently been appointed to assist with the driving. There was evidence from speaking to the ladies, reading files and from photographs around the home that people were able to develop friendships and relationships. The ladies take part in the weekly shopping and meals included freshly cooked produce. The soft diet would have been improved if the food had been served in its separate components rather than all pureed together. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality outcomes in this area were excellent. This judgement was based on all the available evidence which included examination of documentation, discussion with the ladies and staff and observation The ladies were involved in discussions about their health care needs and had access to health care professionals and special equipment as required. They were protected by the medication systems and practices. EVIDENCE: One care file and observation showed that a health risk plan was being followed after advice from the speech therapist. A member of staff said the difficulty experienced by the lady had reduced as a result of this and the plan was due to be reviewed. Another Health action plan, again written in the first person, described the risks of tissue damage developing due to friction and pressure and identified the pressure relieving equipment provided to reduce the risk. Medication sheets were checked and all were up to date. The starting balance of medication received was shown on every MAR sheet. Staff recently had medication training given by a major pharmacy. Medication guidance was posted on the door of the medication cabinet. The senior support worker spoken with displayed a good knowledge of the medication in use and was able to describe the system of receipt, checking and disposal of medication. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 14 Staff had made special efforts to avoid any disruption to medication when the local health centre was damaged by fire. Care files showed that people received professional support, advice and equipment as their needs changed. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality outcomes in this area were good. This judgement was based on all the available evidence which included an examination of recruitment and selection processes and the complaints procedure, discussion with staff and service users and observation. Systems were in place for the protection of the ladies living in the home. EVIDENCE: The complaints procedure was on display and showed that the organisation’s central office had to be informed of any complaints. One complaint from a neighbour regarding overhanging trees had been satisfactorily resolved by the housing association that owns the property. The home had safe systems with a clear audit path for managing the ladies money. The organisation provides adult protection training for staff, which includes a refresher course for existing staff. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29 and 30 Quality in this outcome area was good. This judgement was based on all the available evidence, which included an inspection of the building, discussion with staff and service users and observation. The home was fit for the stated purpose, clean and well maintained. The ladies had individualised their own rooms and communal sitting areas to create a ‘homely’ environment. EVIDENCE: The washing machine mentioned in the last report and the dryer have been replaced. Most of the washing is now done during the day. These measures had reduced the disturbance caused to people in rooms close to the laundry. A self- closing device, linked to the fire alarm, had been fitted to the storeroom door following advice from the Fire Officer. This was seen to work effectively when the fire alarm was accidentally activated during the visit. Bearing in mind that the home was purpose built the outside appearance was disappointingly institutional. This was also apparent in some of the indoor areas inside. e.g. a high internal shaft in the main corridor provided natural light but was a source of heat loss. Internal doors with wire reinforced fire resistant glass were less than domestic in appearance. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 17 However, overlooking these architectural oversights the staff and ladies who live in the house had made their own rooms and shared areas suit their personal tastes and an appearance of comfortable domesticity prevailed. All areas were clean and décor and floor coverings stood up well to the regular passage of wheelchairs. The home was clean and free from unpleasant odours throughout. A large patio area could be accessed easily from living rooms and it was apparent that one person at least gained pleasure from the garden. Much of the large garden however was sloping lawn therefore not easy to access by wheelchair. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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): 31, 32, 33, 34 and 35 Quality outcomes in this area were good. This judgement was based on all the available evidence, which included an examination of recruitment and selection processes, inspection of a training record, discussion with staff and service users and observation. The home had an effective recruitment and selection and training programme. Staff were supportive and respectful and there was a friendly relationship observed between the staff and the ladies who lived in the home. Routines and tasks revolved around the needs of the ladies. EVIDENCE: The home had been using agency staff two of which were working shifts on the day of the visit. This was to maintain staffing cover for two staff who were on maternity leave and the knock on effect of an internal appointment. Night staffing arrangements had changed to two waking staff in response to the changing needs of the ladies. The same team of agency staff were used and both those seen were familiar with the home and the care needs of the ladies. All staff supported the ladies in a friendly and respectful manner. The file of a newer support worker was examined and showed a thorough recruitment and selection procedure had been followed. Notes of the interview could be linked to the employee specification. A formal induction training for new staff showed that Fire safety and the layout of the building had been covered on the first day. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 19 Staff had the opportunity to comment on the effectiveness of the induction training at the end of their induction period. The staff file gave a clear picture of the training received and included a training plan with dates. The support worker confirmed she had attended previous training though this had not been signed off on the training record A good 6-week probationary report had been completed, but had not been dated or signed. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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): 37, 38, 39, 40, 41, 42 and 43 Quality outcomes in this area were good. This judgement was based on all the available evidence, which included examination of documentation, discussion with the ladies, staff and a visitor and observation. The manager was very experienced but had yet to complete her registration or the NVQ award in Management, which is a requirement of the role. The home was being well managed with the involvement of the people who lived in the house and to cause the minimum disruption to their lifestyles. EVIDENCE: The recently appointed manager has many years experience having worked in the home since it opened and prior to that with some of the ladies. She has achieved NVQ2 and 3 and the assessor’s award but has not yet done the NVQ4 in management. The next course will start early in 2007. She is currently applying to be registered with the CSCI. The staff said the management change had been seamless so there had been no disruption for the ladies. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 21 Communication between staff appeared good with excellent recording in care files. A general communication book was used for information about household matters and maintenance issues. Minutes of the last staff meeting were inspected and covered Health and Safety issues specific to each lady in the house, training (the speech therapist had been asked to do in house training), night fire safety, mealtimes and presentation and food hygiene issues. The ladies had their own finance accounts with income and expenditure documented on individual sheets and attached receipts. It was explained that this was double-checked when each sheet was completed and at staff handover time. The fire safety check records were up to date. These are done on Sundays by the weekend staff. The annual fire risk assessments were due to be carried out in December. Monthly Health and safety checks of the building included every room. Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 22 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 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 4 26 3 27 3 28 3 29 4 30 3 STAFFING Standard No Score 31 3 32 4 33 4 34 4 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 4 4 3 LIFESTYLES Standard No Score 11 3 12 4 13 x 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 4 3 x 2 3 3 4 3 3 3 Broad Lane DS0000001428.V310910.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 3. Standard YA37 Regulation 8 Requirement The registered manager must complete the registration process and achieve a qualification at level 4NVQ or equivalent in management and care Timescale for action 31/12/07 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 2 Refer to Standard YA17 YA41 Good Practice Recommendations Soft diets should be served in a manner which allows the person eating the food to taste the different components of the meal. 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