Inspection on 15/05/07 for Carr Manor Road

This inspection was carried out on 15th May 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carr Manor Road 25/09/06

Carr Manor Road 30/01/06

Carr Manor Road 20/09/05

Carr Manor Road 25/02/05

Carr Manor Road 24/01/05

Carr Manor Road 09/03/04

Carr Manor Road 27/03/03

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 Carr Manor Road 34 Carr Manor Road Leeds West Yorkshire LS17 5AZ Lead Inspector Hebrew Rawlins Key Unannounced Inspection 15th May 2007 09:30 Carr Manor Road DS0000001435.V331825.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 Carr Manor Road DS0000001435.V331825.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. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Carr Manor Road Address 34 Carr Manor Road Leeds West Yorkshire LS17 5AZ 0113 288 8449 0113 2888449 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.c-i-c.co.uk. Community Integrated Care Mrs Sharon Hutchinson Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th September 2006 Brief Description of the Service: The South Yorkshire Housing Association owns the property at Carr Manor Road. The care and services are provided by Community Integrated Care which is a registered charity caring for people with special needs. Mrs Sharon Hutchinson manages the home on behalf of the latter. Carr Manor is a semidetached house located within 2 miles of Leeds City Centre and is at the end of a quiet street. The home has been open since August 1996. There is a wide range of shops and leisure facilities within easy reach of the property. The home has 5 bedrooms. All are single rooms with wash hand basins. There are two fully equipped bathrooms comprising a bath, shower and toilet. All bedrooms are decorated to individual taste and choice. Service users are encouraged to buy personal items for their own use, which helps to create a homely atmosphere within the establishment. Service users are encouraged to make full use of the entire house and garden and the facilities within, including television, video and music system. The weekly fees are around £1028.68 as per individual service contract. Additional charges are made for hairdressing, private chiropody and newspapers Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk One inspector carried out this unannounced visit on the 15th May 2007. The purpose of the inspection was to monitor progress in meeting any previous requirements and recommendations and to make sure the organisation was providing a good standard of care for the people who use the service. The methods used at this inspection-included time spent looking at records held in the home’s office and talking with the registered manager. Staff were also spoken with as well as people living in the home. Questionnaire type surveys were also sent to health professionals. Two were returned from GP’s. This information has also been used in the preparation of this report. In addition to this, information gained from a pre-inspection questionnaire and the organisation’s service history records were also used. Feedback was given to the manager at the end of the visit. Thank you to everyone for the pre inspection information, returned surveys, hospitality and assistance on the days of the visits. What the service does well: People receive a good standard of health care. The staff team work well with the health professionals involved with people living in the home. In the survey returned by health professionals the GP’s said “ The staff at this care home Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 6 bring patients down the GP surgery when they need medical attention in a appropriate way”. “We rarely need to visit the home and we encourage this use of our services when appropriate”. Staff are good at encouraging family involvement and supporting people to keep in touch with family and friends. The home is very homely and clean. Furnishings are of a good standard. Staff interact well with people living in the home and treat them as individuals. They make efforts to give people in the home good experiences within the wider community, particularly with regard to holidays. What has improved since the last inspection? What they could do better: Water damage in one of the lounges should be addressed. The Medication Administration Records (MAR) sheets must be signed when medication is administered. If not this could create a situation where medication is given twice which could be a risk to people’s health. Copies of the operations manager’s reports (regulation 26) must be regularly sent to the Commission for Social care Inspection. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 8 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 Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4 and 5. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The information provided about the service is good and gives people that are considering using the service the opportunity to decide whether or not the home can meet their needs. The assessment procedure is thorough and people can be sure that the home will not offer to provide a service unless the staff are able to meet their needs. EVIDENCE: The Statement of purpose and Service User Guide are documents that give information on what the home can provide. Pre-admission assessments are carried out before anyone moves into the home. This is done to a good standard with lots of detailed and individual information. The manager of the home, the operations manager and Social Services are all involved in this. People in the home and their relatives have been consulted and contributed to the assessment. The moving process is tailored to meet the person’s needs and the needs of their relatives. Visits were arranged and moving in date agreed by all concerned. The assessment period also considered the needs of the current people in the home. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 10 All people in the home have a contract with the organisation that outlines all the terms and conditions People who were able to said the home and service provided is great. One person said, “this is my home” and “these people are my friends”. A relative respond to the questioner said “we could not have chosen a better place. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People in the home are encouraged to make decisions about their day to day lives. Support plans and risk assessments provide clear detailed instruction on how peoples’ needs are to be met. EVIDENCE: Risk assessments are in place to reflect lifestyle choices. In discussion with people using the service it was clear that they are supported to take risk in order to enjoy life’s experiences. During the visit people in the home were discussing where to go for their summer holiday. Care plans give detailed instruction on how peoples’ needs are met. The information is person centred and is written in the first person, giving good information on likes and dislikes and preferences with care and support. There Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 12 is also information on peoples’ leisure and recreational needs. The care plans are reviewed regularly and any changes made are well documented. Staff have a good knowledge of peoples’ needs. They were able to describe the care they give and talk about detail of how people like to be supported in their daily routines. They showed a good awareness of the support plans and risk assessment. Key workers carry out a monthly review of support plans with people in the home. Due to the complex needs of some of the people it is difficult to hold formal meetings with them. Some people in the home do not use verbal communication so are observed for their body language and facial expressions in response to questions. People were offered choices throughout the day, for example what to do, where to go, what to eat, whether to spend time in one lounge, another lounge or in their own room. Staff respected peoples’ choices and responded well to their requests. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 13 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16 and 17. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are supported to make choices about their lifestyle and supported to develop their life skills. Appropriate activities are arranged and a good, healthy and varied diet is offered. EVIDENCE: Menus showed that there is plenty of choice and variety. The mealtime is relaxed, and people are able to eat in comfortable surroundings. Staff were seen to make available to people using the service drinks throughout the day. One person spoken with said “they are all good cooks” “sometimes they let me help” “I like my food”. Where there are links and contacts with family members, the staff encourages these to continue. Families supplement the input that staff give, taking their Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 14 relatives out and involving them in their own families’ lives. People living in the home are supported to take part in appropriate activities within the community as well as the home. Some people attend day care centre such as TACT, Potternewton centre or work part-time. A holiday is organised each year, staff and people living in the home spoke enthusiastically about the coming one and previous holidays. Staff were seen to support people with courtesy and thought for their dignity. They said it was important to make sure that people are as independent as possible for their dignity and self esteem. People are encouraged to get involved in household tasks. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Staff place a good deal of importance on continuity of care, whether that be from the staff team at the home or from community based health care professionals. EVIDENCE: There was evidence that care plans and the outcomes of these were being regularly reviewed. The level of detail in support plans on how personal care and health related tasks are to be carried out makes sure peoples needs are fully met. Staff have good knowledge of their likes, dislikes and preferences. Plans have details of any health professionals that people see. A GP’s respond to the questioner send said “ The staff at this care home bring patients down to the GP surgery when they need medical attention in an appropriate way. We rarely need to visit at the home and we encourage this use of our services when appropriate”. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 16 No people using the service manage their own medication. The Medication Administration Records (MAR) sheets were checked; it was found not all were signed when medication is administered. If not this could create a situation where medication is given twice which could be a risk to people’s health. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are protected by a robust complaints procedure and adult protection procedure. EVIDENCE: The organisation’s recruitment procedures follow good practice guidelines, including the thorough vetting of staff before employment. Adult Protection training is included in the basic training that all staff undergo. The home’s Policy File contains good detailed procedures to follow. The manager welcomed the opportunity to address concerns before they grew into serious complaints. No complaints have been received by the home in the past year. There are appropriate procedures in place for the safe management of personal allowance, the records showing that proper accounting procedures are adhered to. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 and 30. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home offers a safe environment for those who live there and provides them suitable accommodation. EVIDENCE: The home is tastefully decorated and furnished throughout. Bedrooms are well maintained and show their individual interests and personality. There is a choice of bath or shower for people living in the home. Standards of hygiene are maintained, with appropriate protective equipment sited around the home. Good practice was seen on the day such as hand washing. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 19 The home offers a warm, comfortable and safe place for people to live. It was clean, hygienic and tidy throughout and nothing was seen that could cause a hazard to people living in the home, staff or visitors. The garden area is enclosed making it a safe for people at the home to use. The manager is thinking of having a summerhouse built for one person who loves to be outdoors. Communal areas in the home offer sufficient space for all who lives there to use and be comfortable. There is a small patch of water damage in the lounge that requires attention. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 and 36. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living in the home are protected by the robust recruitment policy in place. Training and support are offered to the staff team. EVIDENCE: Well over half of the staff team have achieved an NVQ (National Vocational Qualification) in level 2 or above. Records are kept of staff’s training and when their updates are due. Staff spoke highly of the training and the support they get from the manager. The company operate a recruitment policy that looks towards employing the most suitable people for individual posts. All interviews are carried out under equal opportunities legislation. Two written references, Criminal Records Bureau (CRB), POVA, Visa and work permits are all check before an appointment is made. Regular staff supervision sessions and staff meetings are held. Written records of the sessions are maintained. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 21 Duty rotas indicated that there are sufficient care staff on duty to meet the needs of the people living at the home. Care staff do the cooking and cleaning with the support of the people living in the home. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,40,42 and 43. People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home is well managed and has a competent management team. This means that the interests of the people living in the home are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The home has an experienced manager. She offers good leadership to staff and interactions were observed between her, people living in the home and staff. Quality Assurance questionnaires are sent out on an annual basis from the company head office. The operations manager makes regular visits and reports Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 23 on the conduct of the home. This involves talking to people living in the home and staff about the home. Copies of these reports must be regularly sent to the Commission for Social Care Inspection. A selection of statutory records and operational policies were inspected, including people in the home care plans, risk assessment, staff rotas, and menus. All records are secure and maintained in accordance with the Data Protection Act. Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 24 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 3 2 3 3 3 4 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 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 3 X 3 3 Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 25 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 YA43 Regulation 24 Requirement Copies of the operations manager’s reports (regulation 26) must be regularly sent to the Commission for Social Care Inspection. This should make sure the service is being monitored and the CSCI kept informed. Timescale for action 31/07/07 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 YA20 Good Practice Recommendations The Medication Administration Records (MAR) sheets must be signed when medication is administered. If not this could create a situation where medication is given twice which could be a risk to people’s health. Water damage in one of the lounge should be addressed. 2 YA24 Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Carr Manor Road DS0000001435.V331825.R01.S.doc Version 5.2 Page 27 - 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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