CARE HOME ADULTS 18-65
Broad Lane 199 Broad Lane Bramley Leeds LS13 2NJ Lead Inspector
Linda Trenouth Unannounced 6th October 2005, 2.00pm 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. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 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 Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Community Integrated Care Ms Caroline Bairstow Care Home 5 Category(ies) of Learning disability (1), Learning disability over registration, with number 65 years of age (4) of places Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19/10/04 Brief Description of the Service: The property at 199, Broad Lane is owned by South Yorkshire Housing Association. The care and services are provided by Community Integrated Care, a registered charity. Miss Caroline Bairstow is the registered manager. 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 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Over the inspection year from April until March, regulated care homes have a minimum of two inspections; these may be announced or unannounced. The last inspection was announced and took place in October 2004. The people who live in the home use the term housemates; therefore this is the term that will be used throughout this report. During the inspection some areas of the home were seen, such as communal areas and some bedrooms. Time was spent speaking with the housemates, manager, staff and seeing care practices. Other inspection methods used were looking at the records, reading care plan documentation, observing and speaking to the housemates and the staff involved with their care. The inspection was unannounced and was in the afternoon over three and half hours. On arrival at the home, the manager and staff were available, courteous and helpful. The home overall was clean, comfortable and appeared in good order. Information about the inspection findings was discussed with the manager Caroline Bairstow at the end of the visit. What the service does well:
The home, which the housemates and staff call, Nelly, is comfortable with a friendly and welcoming atmosphere. The environment is clean, tidy and very well maintained. The housemates were clearly comfortable, relaxed and content. Housemates are meaningfully involved with the running of their home and lives. The care planning is person centred and genuinely includes the individual in all the decision-making. The individuals also participate in recruitment, staff training and day-to-day decisions within the home. The staff only give support where necessary, the preferences of the individual are clearly central to the care. The staff support the housemates to personalise and individualise their rooms. Individuals were also involved with the decor and choice of furniture throughout the home. Record keeping is of a high standard and the assessment and care planning provide good detail and a clear structure to the care provided at the home.
Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 6 The staff are positive and progressive in furthering the residents abilities within the home. Individuals are provided with a large and varied range of activities, leisure events and holidays. They also have good opportunities for personal development and participating in integrated and meaningful activities. The manager and staff encourage individuals to be independent and to reach their full ability. The organisation has robust recruitment and selection procedures and provides staff with good induction and specialist training. The manager provides staff with regular monthly supervision and annual appraisals. The organisation has a good training policy and a clear commitment towards staff completing induction, foundation and NVQ awards. The manager and staff have already achieved the necessary standard for NVQ training, this is commendable. 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 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 3, 4 and 5. Possible new housemates are fully assessed and have the opportunity to visit and test-drive the home before they move in. Housemates and their relatives are clear about their rights whilst living at the home, from the information and the contract they are given. EVIDENCE: Housemates said they were given the opportunity to look around the home and stay before they moved in. The individual contracts were seen and signed. All the housemates have been given copies of the service user guide and statement of purpose. The information outlines their individual rights whilst living at the home. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, and 9. Staff treat residents with dignity, helping them to make decisions in all aspects of their lives. Housemates contribute meaningfully and are central to their personal goals and essential life plans. EVIDENCE: The housemates sign their essential living plans, to show they agree and understand the content. It was clear that they were aware of their care plans and felt that they decided when they needed assistance or support from staff. The plans are reviewed by the individual and key worker every month. The manager and staff team work hard to make sure that the housemates are at the centre of all decision-making. The house meetings include everyone. The focus of the meetings is to discuss everything that effects the home and procedures are reviewed after discussion with the housemates. All housemates are encouraged to communicate in the meetings; communication aids are used such as writing boards. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 10 Risks assessments are undertaken and included as apart of the overall living plan of an individual. These assessments are discussed and agreed with the housemates to ensure their continued safety whilst making sure they remain as independent as possible. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 13, 14, 15, 16. Staff support residents to become part of, and participate in, the local community, in accordance with their wishes. Residents lead fulfilling lives outside as well as within the home. Residents are encouraged to participate in social and leisure activities, to maintain links with their friends and family and to exercise choice and control over their lives. EVIDENCE: The housemates are involved with the domestic routines within the home such as the laundry and mealtimes. They decide what food is to be prepared and help with the shopping. Individuals also choose the furniture in the home such as new carpets and sofas. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 12 The staff help housemates choose from a mixed and interesting programme of activities both within the home and wider community. Two housemates attend day centres and also choose from integrated activities at the local colleges. Housemates talked about the drama and art classes they attended. One housemate said she was waiting to go on an aromatherapy/massage course. Housemates talked about special events, there had been a surprise birthday celebration for one housemates 70th birthday and she was clearly moved by the occasion. Two housemates had been on a short break to London to see a show, and others to Blackpool and Euro Disney. All individuals had chosen where they wanted to go. Some housemates also attended leisure clubs at Gateway. The manager and staff are helpful and thoughtful in supporting housemates to see family and friends. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20. The residents physical and emotional needs are met, and are supported in a way they prefer. Medication procedures make sure that residents are protected when taking medicines. EVIDENCE: The essential life plan reflects the needs and strengths of the individual. One housemate stated that staff always helped them in a way they preferred and this was discussed at the monthly reviews. From looking at records it was clear that staff managed complex and changing needs. Appropriate training was organised to meet the changing need of an individual, to make sure they were comfortable and safe. The staff have received training in medication and have a good understanding of the policies and procedures. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23. The home has complaints and adult protection procedures in place, which protect the residents. EVIDENCE: Housemates said that they were able to talk to all the staff about any concern they. They felt that they got on well with the staff and that staff listened to them. Induction training and supervision for staff also confirmed that appropriate support networks were in place for staff to discuss their concerns. The home Nelly regularly has house meetings. The housemates and staff all contribute to the agenda and decision making of those meetings. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 15 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, 28, 29 and 30. The residents live in a comfortable and clean environment. The home suit the housemates needs and lifestyles. EVIDENCE: The parts of the home seen were very clean and well maintained. Housemates are encouraged to participate in the general domestic routines. Each housemate has their own bedroom adapted to meet their particular physical need. Each bedroom was decorated differently and showed the different tastes and personalities of the residents. From the bedrooms seen it was clear that residents are encouraged to buy furniture and other items they want. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 16 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, 34 and 36. Safe staff recruitment procedures are followed to protect the housemates. Housemates are supported by competent and trained staff. The manager makes sure that there are enough staff are on duty in order to meet the needs of residents. EVIDENCE: Recruitment records for newly appointed staff were seen. Staff files showed that safe recruitment procedures were followed and that all required references and CRB (Criminal Records Bureau) checks were in place. Staff receive thorough induction and foundation training. The staff progress to NVQ level 2 and 3. The home has more than 50 of staff now qualified to NVQ level 2 and above. Two members of staff have NVQ level 3. The manager has completed NVQ level 4 in Management, now fully meeting the standard. This is in addition to many years experience in supporting and caring for adults with a learning disability. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 17 A training programme was in place, which includes moving and handling, health and safety, food hygiene, first aid and fire safety. Specialist training has also been undertaken in medication and the management of challenging behaviour. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 18 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, 39, 42 and 43. The home is well managed, the interests of the residents are seen has very important to the manager and staff and are safeguarded at all times. The housemates are included in all the decision-making and their views and opinions are sought. The home has a good quality assurance system, which is appropriate to the size and needs of the home. Health and safety may be compromised by the inability of staff to view the nurse call system. EVIDENCE: The manager and the provider work together to make sure that the home is well run and the needs of the residents are met. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 19 Housemates spoken with confirmed that they are included in daily decisionmaking and their views and opinions are sought. Regular house meetings are held and documented. The housemates vote an employee of the month at their meetings and give positive praise about their work. Housemates felt that the manager and staff listened to them and acted upon their grumbles and concerns. Health and safety concerns are acted upon responsibly. Concerns were raised however, that the nurse call monitor is placed in a side storage room. This is to maintain the look of the homely environment. This monitor must be easily viewable and an automatic door closure must be fitted. The manager must seek guidance from the fire officer to resolve this problem. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 20 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 4 4 4 3 Standard No 22 23
ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 4 4 4 4 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x 3 4 3 Standard No 11 12 13 14 15 16 17 4 4 4 4 4 3 x Standard No 31 32 33 34 35 36 Score 3 3 x 3 x 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Broad Lane Score 4 3 3 x Standard No 37 38 39 40 41 42 43 Score 4 4 4 x x 2 3 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 21 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 42 Regulation 23 Requirement The nurse call monitor must be in view to the staff, a door holder must be agreed with the fire officer. Timescale for action 1.01.06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations no recommendations. Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 22 Commission for Social Care Inspection Aire House Town Street Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
© This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Broad Lane 20051006 Broad Lane UN Stage 4 S1428 V258164 J52.doc Version 1.40 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!
