Inspection on 12/10/05 for Cardigan Road

This inspection was carried out on 12th October 2005.

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

Other inspections for this house

Cardigan Road 29/11/06

Cardigan Road 22/03/06

Cardigan Road 16/02/05

Cardigan Road 02/08/04

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 Cardigan Road 66 Cardigan Road Leeds West Yorkshire LS6 3BJ Lead Inspector Kathleen Firth Unannounced Inspection 12th October 2005 11.45 Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cardigan Road Address 66 Cardigan Road Leeds West Yorkshire LS6 3BJ 0113 275 2124 0113 2752124 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) St Anne`s Community Services Mrs Lorraine Shaw Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2005 Brief Description of the Service: Cardigan Road provides accommodation for up to eight men and women who have a learning disability. Nursing care is not provided at the home. It is operated by St. Anne’s Community Services. The home is situated close to the cricket and rugby grounds in Headingley, Leeds. There are shops, pubs, GP surgery, and other amenities within walking distance of the home. The home is well served by public transport and there is parking alongside the garden area at the rear of the building. The accommodation is provided over four floors, the home being accessed by either the lower ground floor at the rear or steps leading up to the front door. There is a stair lift on the stairs from the lower ground area. Service users have single rooms and one person has a self contained flat. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over three hours by one inspector on Wednesday 12th October 2005. The inspector looked around the building, spoke with one resident, manager, staff, examined records including care plans, staff rosters, staff files and the Statement of Purpose. The Manager and staff were very helpful during the inspection. What the service does well: What has improved since the last inspection? The home now has its full complement of staff. Formal staff supervision sessions are now in place as required. All residents have a comprehensive care plan in place highlighting their needs and tasks that staff need to do in order to meet these. Improvements have been made to the way residents choose their meals resulting in them eating a varied and nutritious diet that takes their own choices into account. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 6 Staff receive fire training as required and one member is now the fire training facilitator. Residents’ records are stored in a way that facilitates easy access. 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. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4, 5 People can be sure that the home will meet their needs and aspirations. The information given to potential residents is sufficient to allow them to make an informed decision about coming to live at the home. EVIDENCE: There have not been any admissions since last year but the manager explained the procedure. The manager will go and assess the potential resident to make sure that their needs can be met at this home. During this assessment aspirations and choices are discussed with the person and their carer. The holistic assessment looks at physical, intellectual and spiritual needs as well as housing requirements. Admissions are tailor made for the individual person and will take as long as is required. Visits can be made as often as the individual chooses and can be of varying lengths of time. Some people decide almost at once that they wish to live at the home whilst others may take a long time. Everyone gets the chance to meet the other residents and to see the room they will occupy. They will also be involved in redecorating the room. Residents have an individual contract in his or her service user guide and these are kept in their own rooms. Evidence was seen that all information given to the residents is presented in a format that is easy for them to understand. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Good communication makes sure that the residents’ needs are met. Appropriate risk assessments with coping strategies are in place. EVIDENCE: All residents have a comprehensive care plan in place that gives information about their needs. There was evidence that the residents and their carers are involved in drawing up these plans; and the format they are in makes sure that they are easily understood. The plans are reviewed on a regular basis although this is not always clearly recorded. All information about the residents is handled correctly and stored in an appropriate way. Residents know that staff keep information about them confidential. Residents are helped to make decisions by staff giving them information and then talking through this with them to make sure they fully understand what is being said. They are then helped to make a decision about the issue. One lady is wanting to buy a double bed so staff have helped her draw up a savings plan that will allow her to do this. One resident does not want to attend day Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 10 care so staff now spend one to one time with him and take him out to do activities of his choice. The residents are involved in the day-to-day decision making at the home. If redecoration is to be done they have a choice in the colour scheme and floor covering. The manager makes sure that residents have some responsibility for certain actions e.g. new keys will be issued at a cost of £5 now if they are lost, residents have been asked not to put dirty ashtrays in the dishwasher. Risk assessments are done for everything that the residents do and families are involved in these as appropriate. One resident has chosen to come home from an event she attends in a taxi rather than have a member of staff collect her. All of the residents go out on a regular basis to the local shops, doctors’ surgeries etc. The manager showed a good awareness of residents’ rights to take risks as well as her duty of care and is able to balance these. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 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): 12, 13, 14, 15, 16, 17 Appropriate activities are arranged for the residents. Residents are supported to keep contact with family and friends. The rights of the residents are respected at all times. EVIDENCE: Residents are supported to follow their own interests and take part in valued activities. Some residents attend day care, one has a job at the provider’s head office, and three attend college where they study computers, art and drama. One resident is learning about gardening and works on a local scheme at a nursery. Individual time is given to the residents on one day each week. A local voluntary group are setting up a scheme to provide leisure activities and two of the residents have shown an interest in joining this. Some of the residents are planning a trip to Blackpool whilst two of the older residents are choosing to go to Whitby instead. Three residents are going on a weekend retreat with people from the church that they attend. The staff help residents to maintain contact with their families and friends. Visitors are able to come at any time and some stay for meals including Sunday lunch. Two staff members took a resident to a family wedding in the Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 12 south of England recently. The residents are seen very much as part of the local community and people “look out” for them when they are out and about. Regular meetings are held with the residents where future activities may be discussed along with any changes that may be happening at the home. Residents are included in the running of the home and are responsible for their own laundry and keeping their room tidy. There is a rota up in the kitchen telling them what they are responsible for on any particular day. Staff encourage the residents to be as independent as possible. They are all involved in shopping for food and are able to choose their own meal twice each week. On the other days they choose from a nutritious menu. What is served each day is recorded in a diary so the manger and staff are aware of what every resident is eating. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 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, 20 Residents are treated with respect and their privacy and dignity maintained at all times. The manager and staff are aware of the residents’ needs. EVIDENCE: All personal care is done in consultation with the resident’s wishes and carried out in the privacy of the bathroom or their individual bedroom. One resident has a flat that has its own en suite facilities and receives her support in this setting. The residents are registered with a local GP practice although one person remained with his own doctor when moving into the home. The manager said that the local healthcare team including the District and Diabetic nurses offers them excellent support and are always willing to offer advice. Evidence was seen that Optician, Dental and Chiropody visits are all organised and in place for the residents. None of the present residents are able to manage their medication although they do keep their own creams. One lady is given her medication on a daily basis and then takes it herself. The home has a policy and procedure in place to manage medication and uses the Nomad system. The local pharmacist is very helpful, collects prescriptions and delivers the medication. All staff have Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 14 completed certified medication training at a local college. Medication records were all correctly maintained and medicines stored correctly. One member of staff takes responsibility for medication at the home. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 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, 23 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve them. Residents are protected from abuse. EVIDENCE: All residents receive a copy of the complaints procedure in the home’s Statement of Purpose. The manager feels that all of the residents are able to voice any concerns that they may have and will talk about anything that annoys them. The home has a Seclusion policy in place that is presented in a format suitable for the residents. Residents have signed to say that they understand and agree with this policy. All staff have received Adult Protection Training and the home has a policy and procedure in place to deal with this issue. The residents collect their own money from the bank weekly. Financial records were all correctly maintained with receipts being available for anything purchased. Each resident has an individual wallet for money handled by staff with records of income and expenditure. The Providers carry out their own audits at the home in addition to the required Regulation 26 visits. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 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, 26, 27, 28, 29, 30 The home offers a safe environment for the residents and provides them with suitable accommodation. EVIDENCE: The home offers a comfortable, homely environment with the fixtures, fittings and décor being of a good standard. It was found to be clean and hygienic throughout and there are sufficient toilet and bathing facilities available for the residents. One resident has her own flat that was being redecorated at the time of the inspection. This offers her the chance to maintain some independence. The lounge offers a comfortable and safe place for the residents to relax and watch TV and listen to music. There is also a fish tank in the lounge and one resident has responsibility for feeding the fish. The dining /kitchen offers sufficient space for the residents to eat their meals in comfort. The basement area that leads out to the garden is used as a games room and the residents spend a lot of their time here. A local bank is redecorating two bathrooms and sorting out the garden as part of Community Challenge. None of the present residents require any specialist equipment but will be assessed for this if their needs change. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 17 Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 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): 32, 34, 35, 36 Residents are supported and protected by the recruitment procedures in place. Staffing numbers and skill mix make sure that the residents’ needs can be met. EVIDENCE: The home has its full staff complement and rosters showed that there are sufficient people on duty on each shift. Flexibility is built into the roster to cater for holidays, sickness and training. The roster is organised to work around the residents’ needs meaning that staff start work earlier two days per week as one resident who goes out on those days requires help to get ready. The staff team at the home works well together and communication is good. Recruitment is carried out to comply with equal opportunities and before staff start working at the home CRB, POVA, Visa, work permits and health checks are made. Two written references are required including one from the person’s present employer. New staff shadow their fellow workers for around two weeks before working as a full team member. Supervision sessions are in place as per regulations with written records being made. The majority of staff have achieved or working towards a National Vocational Qualification. Staff meetings are held every six weeks with an Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 19 agenda and minutes. The minutes are available for everyone and they sign to say they have read these. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 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, 39, 40, 41, 42 The home is well managed, the interests of the residents are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager holds the Registered Manager’s Award, NVQ level 4 in care and management and has worked in the caring profession for many years. She has an open door policy that was seen during the inspection with residents and staff approaching her to talk about various things. Regular residents meetings are held at the home. Quality assurance questionnaires about the service are given to residents and any other regular visitors to the home to complete on an annual basis. The annual service review is due to be carried out in November. All records seen were properly maintained and stored correctly. Daily records of each resident are kept and all staff are well aware of anything happening. Residents and their families are made aware that they can see their records. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 21 When there is a review of care held the resident and their family or representative are invited to be there. The residents are all registered to vote although only about half of them choose to do so. The manager has overall responsibility for health and safety at the home although staff are trained in this area. Fire bells are tested weekly and annual checks are made to all appliances. Records are kept daily of the fridge and freezer temperatures. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 X 3 4 Standard No 22 23 Score 3 4 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 3 3 3 N/A 3 LIFESTYLES Standard No Score 11 X 12 3 13 4 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 X 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cardigan Road Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 4 3 3 X DS0000001431.V252724.R01.S.doc Version 5.0 Page 23 Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA6 Good Practice Recommendations Reviews of residents’ care plans and any changes made must be clearly recorded and dated. Cardigan Road DS0000001431.V252724.R01.S.doc Version 5.0 Page 24 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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