Inspection on 25/09/06 for Carr Manor Road

This inspection was carried out on 25th September 2006.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Carr Manor Road 15/05/07

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 25th September 2006 09:30 Carr Manor Road DS0000001435.V310186.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.V310186.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.V310186.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.V310186.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 30th January 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 £1010.31as per individual service contract. Additional charges are made for hairdressing, private chiropody and newspapers Carr Manor Road DS0000001435.V310186.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 This was an unannounced inspection, which took place on the 25th September 2006. On the day the inspector was in the home from 9.30am until 3.00 pm. The last inspection took place in January 2006. Since then there has been no other visit to the home. The purpose of this inspection was to check if the requirements identified at the inspection in January 2006 were being dealt with and to assess the quality of care being provided to service users in the home. During the inspection I assessed all the key standards, these are identified in the main body of the report. I looked in detail at the care of all five-service users in the home. I looked at their care records, I spoke to the service users about their care needs and to the staff about how they deliver care, I looked at the environment and observed care practices. I also spoke to service users in the home, carried out a tour of the building and looked at other records, which included maintenance records, staff files and training records. Information was requested from the home prior to the visit, this was provided and was used during the inspection. Comment cards for service users and relatives were left at the home; these provide people with an opportunity to share their views of the service with the CSCI. A number of direct quotes from service users and staff have also been included in the report. Feedback at the end of this inspection was given to the senior in charge. I would like to extend my thanks to everyone who contributed to the inspection and for the hospitality during the visit. Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 Page 6 What the service does well: 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. Carr Manor Road DS0000001435.V310186.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 Carr Manor Road DS0000001435.V310186.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): 1, 2, 3, 4 and 5. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users and their representatives have access to clear detailed information about the services provided by Community Integrated Care and can be assured that their needs will be met. Prospective service users have the opportunity to visit the home, stay for a meal and speak to other service users before making any decisions about admission. The home carries out a pre-admission assessment to make sure that it can meet the person’s needs. EVIDENCE: There is plenty of written information about the home for people to read. Copies of the statement of purpose and service user guide were seen and copies of previous inspection reports are also available. There were assessment details in all of the care records sampled, and staff said that they had enough information about the care needs of people before they were admitted. It was clear that prospective service users are given the opportunity to visit the home as many times as they like. One person said she visited three times Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 Page 9 before deciding to move in. Another service user told me that she liked it very much and didn’t like anywhere else and this was her home. Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 Page 10 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 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Because of service users communication and sometimes-physical disabilities staff help service users choices by skilled observation. Service users choices are respected and activities are based on their preferences and abilities. The new paper work for care planning has the potential to provide good care records if used properly. However, new care plans are not in place for all service users, so there is opportunity for those service users needs to be overlooked. EVIDENCE: All of the care records were inspected; some were in the new format others were in the old style care records. It was difficult to find information in the old format on service users care plan for cultural and spiritual needs. Service users and staff confirmed they had been involved in the drawing up of the care plans. Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 Page 11 Care plans are reviewed monthly, but these reviews are not always robust and do not show what factors have been taken into consideration. For example, in one case the records state ‘reviewed no change.’ In all of the care records sampled there was evidence of health needs being met, by dental appointments, chiropody, optical prescriptions and visits from GPs and district nurses. One survey card have been returned from GPs it indicated GP was impressed not only by the care given to service users but also by the knowledge of staff about service user’s health care needs. Through observation on the day of the inspection, and by speaking to service users and staff it is clear that the privacy and dignity of service users is respected. Staff are made aware of the importance of respecting privacy, dignity and confidentiality in their job descriptions and codes of conduct, as well as through the company’s policies and procedures and their training. This was confirmed through discussions with staff. Staff were able to give examples of how and why this is important. Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 Page 12 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, 12, 13, 14, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users choices are respected and activities are based on their preferences and abilities. Service users said the food was good and staff always ask what they want. EVIDENCE: Personal background information in case files showed that activities are tailored to the interests of service users. Information showed that people had been consulted about the type of activities that they would like to be involved in. These included going to pubs, restaurants, leisure centres, shops, cinema, TACT and Potternewton Centre. Some care plans were detailed and gave information on likes and dislikes of service users, particularly about preferred times for going to bed and getting up in the morning. One service user said that she goes to bed between 10 – 11.00pm and gets up in the morning when she “feels like it”. Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 Page 13 People have a choice of menu and are asked what they would like to eat. Meals were appetising and independence wherever possible was encouraged. Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 Page 14 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The new care plans give staff clear and detailed instructions to follow which makes sure that all aspects of the service user’s health and personal care needs are met. Medication for service users is managed in a safe and professional way by staff, to ensure service users receive the correct medication at the correct time. EVIDENCE: It was clear that service users and relatives are involved in the development of the care plan and health care needs are met. There were records of visits by or to community psychiatric nurses, GPs, and chiropodists. A senior care worker followed proper procedures when administering medication. Medication administration records were looked at and found to be in order. Service users have a choice about sitting in one of the lounges or remaining in their rooms, where they were surrounded by personal possessions. Care staff were observed explaining what they were doing when assisting people and trying to encourage their cooperation. Carr Manor Road DS0000001435.V310186.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 and 23. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Systems are in place to help service users or their relatives to make complaints. Adult protection training is needed for some staff to ensure all service users’ rights are protected. EVIDENCE: The appropriate policies and procedures were seen to be in place with all the relevant details. Talking to staff on the day it was evident they are all clear on their responsibility about reporting any allegations of abuse. However from checking the training records there are some staff who have not yet had adult protection training. In order to maximise staff awareness and minimise risks to residents, all staff including members of the ancillary team should be trained on adult protection and abuse. The home has not received any complaint since the last inspection. Carr Manor Road DS0000001435.V310186.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, 26, 27, 28 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home offers a safe, well-maintained environment for the service users and they have access to the garden areas easily if they so choose. Communal areas and service user’s bedrooms are decorated and furnished to a good standard offering safety and comfort. EVIDENCE: All areas of the home were inspected. The home is decorated and furnished to a good standard throughout and the communal rooms offer a safe and comfortable space for the service users. All areas of the home were clean and tidy and nothing was seen during the inspection that could cause a hazard to service users. Service users have access to a well-maintained garden, which now has handrails at the rear of the building to promote independence. Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 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): 32, 34, 35 and 36. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff demonstrated a good level of knowledge of individual service users and seemed to understand the importance of encouraging service users to maintain their independence and dignity. Regular staff supervision takes place. EVIDENCE: The home operates a recruitment procedure based on equal opportunities and ensuring the protection of service users. Written references are taken up and Criminal Record Bureau Checks are made before appointments are confirmed. Staff have had regular formal supervision. Those staff spoken with said they are able to access any relevant training courses and are encouraged to do the NVQ awards (National Vocation Qualification). The percentage of care staff with NVQ level 2 was 50 . The home has a rolling programme for NVQ training. The staff team were observed carrying out their roles in a calm and professional manner. They were seen explaining things to the service users, reassuring them before interventions were carried out. Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 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): 37, 39, 40, 41 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff feels well supported by the manager. They staff confirmed that she offers excellent support and make herself available to discuss any issues that may arise. EVIDENCE: Policies and procedures are located in the office and staff said these documents are readily accessible. All records are secure and maintained in accordance with the Data Protection Act. Speaking with service users and staff it was clear that they feel the manager offers excellent support and is always prepared to listen to them. Everyone spoken with felt that they could approach her if they had any problems or concerns. Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 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 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 2 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 3 28 3 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 x 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 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 x 3 3 3 3 x Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 Page 20 yes 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 YA6 Regulation 15 Requirement New care plans must be in place for all service users, to ensure those service users needs are not overlooked. (raised at last inspection) In order to maximise staff awareness and minimise risks to residents, all staff including members of the ancillary team should be trained on adult protection and abuse. Timescale for action 01/12/06 2. YA23 13 01/03/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 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. Extracts may not be used or reproduced without the express permission of CSCI Carr Manor Road DS0000001435.V310186.R01.S.doc Version 5.2 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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