Inspection on 29/11/06 for Cardigan Road

This inspection was carried out on 29th 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cardigan Road 22/03/06

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 Stevie Allerton Key Unannounced Inspection 29th November 2006 09:30 Cardigan Road DS0000001431.V302812.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 Cardigan Road DS0000001431.V302812.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. Cardigan Road DS0000001431.V302812.R01.S.doc Version 5.2 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.V302812.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd March 2006 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. Current charges are from £426.46 to £482.45 per week. Cardigan Road DS0000001431.V302812.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out without prior notification and was conducted by one inspector over the course of a day, starting at 11.00am and finishing at 6.15pm. It was the first key inspection to be made by this inspector. The Manager was on a training course and not expected on duty until after 4.00pm, but other staff team members assisted the inspector throughout the day. The inspector would like to thank everyone who took the time to talk and express their views. Easy-read survey forms were sent out to service users prior to the visit and six were returned. Survey forms were also sent out to a selection of health and social care professionals and two were returned. Before the visit, accumulated information about the home was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI since the last inspection, including reports from other agencies, such as the Fire Officer. This information was used to plan this inspection visit. The inspector case tracked three service users. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, the inspector assessed all twenty-one key standards from the Care Homes for Younger Adults National Minimum Standards, plus other standards relevant to the visit. The inspector spent time with identified service users and spoke to relevant members of the staff team who provide support to them. Documentation relating to these service users was looked at. Where possible, contact was also made with external professionals, to obtain their opinions about the quality of services provided at the home. What the service does well: The home provides a supportive environment in which service users can lead interesting and fulfilling lives. They are assisted and encouraged to be a part of the local community and to take part in everyday activities, such as shopping and sharing household tasks. There are opportunities to attend colleges and to gain skills that may be useful in getting some employment. The staff team are well trained and know how to support each of the service users so that their needs are met. They know how to safeguard people who may be vulnerable. Cardigan Road DS0000001431.V302812.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. Cardigan Road DS0000001431.V302812.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 Cardigan Road DS0000001431.V302812.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): 2&3 Quality in this outcome group is good. This judgement has been made using available evidence, including a visit to the home. Information available to prospective service users is good and outlines what the service can provide. Current service users continue to receive support at a level that is suitable for their assessed needs, adjusted as their needs change. EVIDENCE: Nothing has changed since the last inspection regarding the written information available, assessment of needs and admissions process. No new service users have been admitted since the last inspection. Discussion with the staff team took place regarding the home’s registration category and statement of purpose and how the service is resourced to meet current service users’ needs. There is specific training for the staff in the needs of the client group and a good record of working in partnership with day care services, etc, as was seen in the care plans. One person selected for case tracking had had a multi-disciplinary assessment in order to meet some behavioural needs and now has one-to-one staff input at set times agreed with her and the placing authority funding her care. Cardigan Road DS0000001431.V302812.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 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The system of care planning in place ensures that service users’ needs are met and that staff have guidance as to the best way to support each person. Service users have the right to make their own decisions; where limitations have been imposed, these have been based on assessed risk and written agreements made where appropriate. Individuals have opportunities to participate in the development of the service and influence decisions that affect them. EVIDENCE: Three service users were case tracked, their care plans looked at in depth. Each service user has a care plan, supported by risk assessments and written agreements, for example, “rationing” of cigarettes so that they last longer. The care plans describe each person’s abilities and normal routines; detailed support plans are then developed, stored in a separate file, providing information for staff on how to support each individual in certain tasks/areas of Cardigan Road DS0000001431.V302812.R01.S.doc Version 5.2 Page 10 assessed need. One of the people who was case tracked had had a recent admission to hospital and there was a new support plan in place for the first 2 weeks after discharge, until his health and abilities improved again. Observation of the interaction between service users and staff indicated that people are encouraged to make their own decisions and to negotiate with the staff where they may need assistance with something. In one care plan seen, a service user did not want to attend a college class one day – he was supported to phone the tutor himself to let them know. In conversation with service users it was clear that some have been able to be involved in specific groups set up by the organisation, where they have been able to influence policies and decisions. Cardigan Road DS0000001431.V302812.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): 12, 13, 14, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. Service users continue to have access to a wide range of opportunities for personal development, including work. They are supported to maintain contact with their families and friends outside the home, the staffing rota arranged flexibly so that those who need support for activities and outings can have it. Meals are of a good standard, ensuring a varied and healthy diet. EVIDENCE: Service users were seen and spoken to throughout the day. One man said he was on his way out to meet his mother in Leeds and go for lunch together. He had been in to Headingley earlier to get his benefit and run an errand for the home. This was his “day off”, as he normally works part-time and attends college as well. He has gained certificates of achievement in literacy and in practical gardening. Cardigan Road DS0000001431.V302812.R01.S.doc Version 5.2 Page 12 Daily routines for each person are shown on a timetable, supported pictorially in some instances. These detail which activity, college or day centre is planned for each person. Pictorial rotas are also in use for the daily household tasks, such as washing up, mopping the kitchen floor or vacuuming, all of the service users playing a part in helping with the tasks around their home. The records showed a wide range of activities, college courses and trips out, also where service users go out and about independently, to the local shops and churches, or to visit their family. A high number of the service users can access their social activities independently. As service users came home from their daytime activities, they called in to the office to let staff know they were back and to talk about their day. One woman was performing with a choir at a Christmas concert that evening. The menus and food records showed a suitable range of choices, the service users’ own preferences accommodated, interspersed with some healthier eating, promoted by the staff. Lunch was taken in the kitchen with the service user who was in at the time, although he did not engage in conversation. Staff discussed how food shopping was organised, with service users taking part in this and in other domestic tasks. Cardigan Road DS0000001431.V302812.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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The staff team are aware of service users’ changing health needs and respond appropriately by re-assessing and adjusting resources. Medication is managed properly. EVIDENCE: Each service user has a key worker, a named member of staff whose role it is to co-ordinate their care & support. This includes ensuring support for hospital appointments and visits to the dentist, optician, chiropodist, etc. Specific staff time is set aside for doing one to one work with a service user; this extra resource has been made available following an assessment of need and ensures that the person receives an agreed amount of staff input at a set time each day. This is detailed within the care plan and on the staff rota so that it takes place as agreed. One service user is awaiting an Occupational Therapy assessment so that appropriate aids for bathing can be obtained. Cardigan Road DS0000001431.V302812.R01.S.doc Version 5.2 Page 14 One of the staff went through the medication system in use in the home. The home uses its’ own monthly recording sheets, with a procedure that has a built-in stock check. There was a clear trail of medications received and booked in and their administration, or return to the pharmacist if unused. There is a policy for self-administration of medication, based on assessment of ability, the document held in the person’s care file. Medication for “as required” use was checked and found to be correct. Cardigan Road DS0000001431.V302812.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 &23 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. Staff are well trained in recognising and dealing with instances of adult abuse, should any arise. The complaints procedure is accessible and has been used to good effect. Service users’ money is safeguarded by the accounting procedures in place. EVIDENCE: The recently updated Adult Protection policy and procedure was seen, which includes the organisation’s policy on training staff in adult abuse awareness. There is a one-day Safeguarding Adults course during staff induction training, plus mandatory refresher training every 2 years. One member of staff was booked on to the training the following day and two more were booked in for March 2007. There is an established complaints procedure, the records showing that one had been received from a neighbour regarding excessive noise. The records showed that this was satisfactorily resolved within the published timescale. Service users’ monies are looked after for them if they are unable to do this themselves. The accounting systems were seen in process during the day. Cardigan Road DS0000001431.V302812.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, 28 & 30 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The programme of continual repair, redecoration and maintenance ensures a safe, comfortable environment for the service users. The home is bright and cheerful and service users are proud of their own rooms. EVIDENCE: A tour of the communal areas of the home was carried out and two service users’ rooms seen by invitation (one of these was a self-contained bed-sit located in the basement). The home was found to be clean and tidy throughout. Communal rooms are furnished in a domestic style and individual rooms are large enough for their occupants to furnish and arrange as they wish. Four bedrooms had recently been decorated. The self-contained flat has easy access from the rear of the building and is disability equipped, with wide doors and a walk-in shower. The laundry is located on the same floor and is well equipped. Cardigan Road DS0000001431.V302812.R01.S.doc Version 5.2 Page 17 Apart from a cupboard door missing in the kitchen, all fittings and equipment appeared to be of a good standard. Service users come and go in the kitchen as they wish, make their own drinks and load/unload the dishwasher. The carpet in the entrance to the living room has become a trip hazard and has been reported for attention by the staff. The home meets current fire safety standards. Cardigan Road DS0000001431.V302812.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): 32, 33, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The service users are supported by a staff team that are sufficient in number to meet their needs, and who receive a high standard of training. The recruitment practices in place protect vulnerable service users. EVIDENCE: Two members of staff were on duty, along with a social work student on placement. The Manager arrived at 4.15pm, after attending a training course, as she was accompanying some of the service users to the Christmas concert later that evening. Both of the Support Workers are established and experienced members of staff with a good depth of knowledge of the service users and the home in general. They were able to find all of the records and policies requested and discuss all aspects of the running of the home, including their own training and support. The home is well on its way to target with NVQ (National Vocational Qualifications) training, most of the staff having achieved this and another worker about to start NVQ. Training certificates were seen for a number of other courses run by St. Annes that the staff had attended. Cardigan Road DS0000001431.V302812.R01.S.doc Version 5.2 Page 19 The recruitment file for the newest staff member was looked at. The full personnel file is held at the Head Office (recently inspected by the CSCI Provider Relationship Manager and assessed as meeting the requirements), with a shortened version kept at the home. This demonstrated that all of the required checks are carried out prior to appointing new staff. The training plan was seen for this new worker: it showed that she was booked on to the organisation’s Induction course, followed by training in the Person Centred Approach, Promoting Non-Challenging Behaviour and the LDAF (Learning Disability Award Framework) standards within the first 6 months. The staffing rota showed sufficient flexibility to allow for service users to receive support at the times they most need it. Cardigan Road DS0000001431.V302812.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, 41 & 42 Quality in this outcome area is good. This judgement has been made using available evidence, including a visit to the home. The home is generally well managed. There is a high standard of service user involvement, both at the home’s level and within the larger organisation. However, greater attention needs to be given to some of the record keeping and to ensure that none of the essential fire training gets missed. EVIDENCE: Service users are involved in the running of their home and some are also involved in user groups at organisational level; two people have been trained in interviewing for staff, for example. A service user survey had just been done and St Anne’s are planning a service user forum for 2007. Minutes were seen of the house meetings, held every month. One meeting was recorded on video, which the Manager said had produced very good feedback for people. Cardigan Road DS0000001431.V302812.R01.S.doc Version 5.2 Page 21 There are monthly visits made to the home by a Service Manager, who makes written reports in accordance with Regulation 26. A newsletter has been produced, using the user-friendly IT equipment; service users were keen to demonstrate its use and said it was good. A selection of regulatory and operational records were looked at, including: • Service users’ care plans • Fire Safety • Accidents • Medication • Health & Safety • Food records • Staff files • Staff training • Rotas • Service users monies. Most records were well kept, with information easy to access. However, it was noted that the fire safety records showed that training for the designated fire facilitator was not up to date, nor had fire training been given to the social work student on placement. Service users care records, too, were sometimes not dated (risk assessments in particular) and the book in which the “fortnightly summary” records are made does not comply with Data Protection, in that records are made on the same page for more than one person, therefore cannot be kept confidential. Cardigan Road DS0000001431.V302812.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 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 3 23 4 ENVIRONMENT Standard No Score 24 3 25 3 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 3 X 2 2 X Cardigan Road DS0000001431.V302812.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 YA41 Regulation 17 Requirement All records must be kept up to date; dates should be added to all documents as they are completed, so that those that are current can be readily identified. Records about service users must be kept in accordance with the Data Protection Act. Fire training must be provided to all staff, and others working in the home temporarily, in accordance with the organisation’s written policies. Timescale for action 31/01/07 2 3 YA41 YA42 17 23(4)(d) 31/01/07 31/01/07 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. 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.V302812.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Cardigan Road DS0000001431.V302812.R01.S.doc Version 5.2 Page 25 - 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. 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