Inspection on 22/03/06 for Cardigan Road

This inspection was carried out on 22nd March 2006.

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 12/10/05

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 22nd March 2006 12:00 Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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.V285579.R01.S.doc Version 5.1 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.V285579.R01.S.doc Version 5.1 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.V285579.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 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.V285579.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 2.25 hours by one inspector on Wednesday 22nd March 2006. The inspector looked round the building, examined records including care plans, Medication records, menus, and food diaries. The inspector was able to speak with three residents who were at home and two of the Residential Care Co-ordinators one of who was present throughout the inspection. The home is very comfortable and the atmosphere welcoming. What the service does well: What has improved since the last inspection? Some work has been done in making sure that any changes to the care plans following review are clearly recorded, signed and dated. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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.V285579.R01.S.doc Version 5.1 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): 2, 3 All residents have an assessment of need prior to admission being agreed. EVIDENCE: There have been no admissions to the home for around eighteen months but there is a procedure in place. The manager will visit all prospective residents and complete an assessment of need. During this she will look at physical, intellectual and spiritual needs. She will also discuss the person’s choices and aspirations with them and their carer. If an admission is agreed following this assessment then the person and their carer can be sure that their needs and aspirations can be met at the home. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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, 10 Good communication makes sure that the residents’ needs are met. Residents know that information is kept about them. EVIDENCE: All residents have an individual lifestyle plan that gives information about their needs. It also informs carers of their lives before coming to live at the home, and contains specific information that may be important to staff if they are to look after them successfully. Evidence was seen that the residents are involved in drawing up the care plans. They sign to say that they understand and agree with the plan once their key worker has gone through this with them. The residents’ individual needs are clearly identified alongside the actions that workers need to do in order to meet these needs. Appointments for Chiropody, Optician and Dentists were all seen in the plans. There was evidence that some of the plans had been updated but a member of staff said that others had been sent to Head Office for typing. Evidence of a six monthly review of care taking place was seen in the files. Risk assessments are in place as appropriate. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 Page 10 Residents know that information is kept about them at the home and that they can have access to this if they choose. All confidential information is kept locked away and stored correctly. Staff are aware of the importance of confidentiality and have received Data Protection training. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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, 14, 17 Residents have opportunities for personal development and are offered a wide range of leisure activities. A good, varied and healthy diet is served at the home. EVIDENCE: The residents live very busy lives with some of them attending college where they follow Computer studies, Maths, English and printing classes. One person has worked in a shop in the past and another helps out at the coffee bar at college. Two residents attend a Rights and Choices group where they mix with members of the community. Some residents attend a church group and join in the activities arranged there. Residents may have one to one time spent with them if this is felt to be more appropriate than them joining in with a group. A staff member had been shopping with one of the residents during the inspection. Trips out and holidays are being discussed at present and three people have a stay at Butlins booked for September. Residents are able to choose where they go on holiday and who with, although there may be financial constraints Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 Page 12 on this. Residents are involved in the day-to-day running of the home and are given as much responsibility as they can manage. They have jobs in the kitchen and are responsible for tidying their rooms and doing laundry. The main meal of the day is served in the evening except on Sunday when everyone has lunch together. Friends and family sometimes join the residents and staff for this meal. Staff include residents in choosing meals and manage to include preferences whilst providing a well balanced diet. Residents are included in meal preparation where possible and they make their own packed lunch where one is required. The food diary shows that staff do manage to provide a good, varied well balanced diet but still take into account the residents’ individual likes and dislikes. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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): 20, 21 The home has a policy and procedure in place to manage the residents’ medication needs. EVIDENCE: None of the present residents are able to manage their medication although one person takes her lunchtime dose with her to day care. The home uses the pre-dispensed Nomad System. All staff can be involved in the administration of medication. They have all been trained in this and the course involved the receipt, storage, administration and disposal of medicines. There are systems in place for the ordering and disposal of medication. The local pharmacist offers very good support to the staff at the home and is able to pass on important information about specific drugs. Staff have been working with the residents on ageing, illness and death using “When I die” booklet. By completing the questions in the booklet people have made their wishes following death known to staff. Where appropriate families have been involved. The inspector was able to look at some of these booklets. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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 the following standard(s): 23 Residents are protected from abuse. EVIDENCE: All staff have received training in Adult Protection and the home has a comprehensive policy and procedure in place to deal with this subject. Staff are able to recognise the signs and symptoms of abuse and know how to handle this situation. There is a Seclusion policy in place that the residents have signed to say they agree with and understand. It is formatted in a way suitable for their abilities. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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 the following standard(s): 25, 27, 28, 29, 30 The home offers a safe environment for the residents and provides them with suitable accommodation. EVIDENCE: The home is clean and hygienic throughout and offers a homely, safe and comfortable environment for the residents. The fixtures, fittings and furniture are of a good standard. There are sufficient bathrooms and toilets for the residents to use and provide them with privacy. A local bank is due to decorate two bathrooms as part of Community Challenge. It was hoped that this would have been done but one of the participants has been ill. One resident has their own self contained flat that offers them the chance to maintain some independence and to mix with the other residents when they choose. Residents’ bedrooms are big enough for them to follow their own lifestyle and have been decorated and furnished to meet the individual’s choice. Some have a double bed, as this is their preference. The residents have their own possessions around them and the two at home during the inspection were happy to show the inspector their rooms. None of the present residents require specialist equipment but staff are aware of how to access an Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 Page 16 assessment from the Physiotherapist and Occupational Therapist if this is felt to be required. The lounge offers a comfortable place for the residents to sit and relax whilst watching television or listening to music. There is a fish tank in the lounge and one resident has the responsibility of feeding the fish. The dining/kitchen is quite large and offers sufficient space for everyone to sit comfortably whilst eating their meals. There is a spacious basement area where residents can play games and the residents tend to spend lots of time here. The garden area is another comfortable space that is well used by the residents in the better weather. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 Page 17 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 Staffing numbers and skill mix make sure that the residents’ needs can be met. EVIDENCE: Staff all understand their own role and responsibilities and those of their colleagues. The home operates a key worker system and all of the residents know who is theirs. The home has a full complement of staff and there is a good team spirit amongst the staff team. Flexibility to cater for sickness, holidays and training is built into the roster. All staff undergo induction training and this is accredited by TOPSS. All care staff have either achieved or are working towards NVQ level 3. Staff meetings are held on a regular basis with an agenda and minutes and everyone is able to contribute to the running of the home. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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 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): 38, 39, 43 The home is well managed with the interests of the residents seen as important and safeguarded at all times. EVIDENCE: The manager offers good support and leadership to the staff team. People are able to approach her if they have any concerns or worries and she encourages staff to put forward new ideas. Residents are able to speak with her and an annual Quality Assurance questionnaire is sent to them each year. The results from the last one are very positive. Regular staff supervision and staff meetings are in place. Written records are kept of the supervision sessions. The manager holds regular meetings with the residents and encourages people to attend and contribute to these. There was no information available at the time of the inspection about the accounting management of the organisation as all this work is carried out at the organisation’s head office. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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 Standard No Score 1 X 2 3 3 3 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 4 ENVIRONMENT Standard No Score 24 X 25 3 26 X 27 3 28 3 29 N/A 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 X 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 X X 3 X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 3 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 3 X 3 3 X X X 3 Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 Page 20 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. 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 should be clearly recorded and dated. Cardigan Road DS0000001431.V285579.R01.S.doc Version 5.1 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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