CARE HOME ADULTS 18-65
Carr Manor Road 34 Carr Manor Road Leeds West Yorkshire LS17 5AZ Lead Inspector
Hebrew Rawlins Unannounced Inspection 30th January 2006 13:00 Carr Manor Road DS0000001435.V276241.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 Carr Manor Road DS0000001435.V276241.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. Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 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.V276241.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 20th September 2005 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. Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. One inspector between 1.00pm 4.00pm carried out this unannounced inspection. The purpose of the visit was to check compliance with the standards and outcomes for service users. The registered manager was present and was given feedback at the end. Time was spent looking round the home, observing practices, talking to residents, examining records and discussions with the manager. Records inspected included care plans, medication records and duty rotas. The last inspection was also unannounced, four requirements were raised, two has been addressed, one is been addressed and the other information is been sort to address this. What the service does well: What has improved since the last inspection? The home has made improvement to service users care plans, the broken bidet have been removed and the areas of the home, which had water damage, has been redecorated. Carr Manor Road DS0000001435.V276241.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. Carr Manor Road DS0000001435.V276241.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 Carr Manor Road DS0000001435.V276241.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): None of these standards were assessed on this inspection. EVIDENCE: Carr Manor Road DS0000001435.V276241.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. Further work is still needed to ensure consistency is applied where care planning is concerned to take in all the required standards. EVIDENCE: There was some variation in the amount of detail that staff recorded in resident’s files. The home manager is in the process of updating the information held in individual service users’ care plan/files. Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 Page 10 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. The Staff support service users to go out regularly to take part in leisure activities. EVIDENCE: Staff reported that they specifically support service users in taking part in leisure activities. The records indicated that people go out regularly. Activities took place on the day of the inspection and service users went out individually with members of the staff team. Staff said that service users accessed community based activities and use a range of facilities that are available in the locality e.g. cinema, theatre, bowling, local pubs etc. This was supported by evidence in the records. One of the service users attends Potternewton Centre and another attends Horsforth Training Centre. Another accesses Tact opportunities service. Staff reported that they support and encourage service users to maintain their relationship with their family and friends. Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 Page 11 The house is large enough for service users to have their own personal space. During the inspection it was noted that service users were able to choose when to spend time alone or in the company of others. Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 Page 12 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): None of these standards were assessed on this inspection. EVIDENCE: Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 Page 13 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. Service users are adequately protected from potential harm or abuse. EVIDENCE: There is an adult protection procedure in place, which includes a whistle blowing procedure. No complaints are recorded since the last inspection. Talking to staff, they are all clear on their responsibility about reporting any allegations of abuse. Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 Page 14 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, 20 and 30. Service users live in a clean, pleasantly furnished home. Each person has his or her own bedroom. A range of comfortable shared space is also available. EVIDENCE: A tour of the building took place. The shared areas were noted to be clean and comfortably furnished. There was evidence of personal possessions in all of the bedrooms. The water damage raised in the last inspection has been addressed and the broken bidet has been removed. The home manager has contacted the landlords to provide handrails and step/ramp to be fitted to the rear kitchen exit. Workmen have being out to access the job and it is hope the work will start in the near future. Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 Page 15 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): 33. The staff team have worked hard to ensure service users are happy with the service on offer. They have a good understanding of ‘good care practice’. EVIDENCE: The care staff on duty were all very pleasant and appeared to be communicating well. They responded to the service users and were seen to offer reassurances and assistance. Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 Page 16 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): None of these standards were assessed on this inspection. EVIDENCE: Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 Page 17 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 x 3 x 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 x 28 x 29 2 30 3 STAFFING Standard No Score 31 x 32 x 33 3 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 x x x x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x x x x x x x x x x Carr Manor Road DS0000001435.V276241.R01.S.doc Version 5.1 Page 18 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 Further developments are still needed, to ensure consistency is applied to the care plans (raised at last inspection). This is being addressed. Residents would benefit from some form of handrails at the rear of the building to promote independence (raised at last inspection) Timescale for action 01/04/06 2. YA29 23 01/04/06 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.V276241.R01.S.doc Version 5.1 Page 19 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
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