CARE HOME ADULTS 18-65
Champion House Clara Drive Calverley Yorkshire LS28 5PQ Lead Inspector
Pamela Cunningham Unannounced Inspection 5th October 2005 11.00 Champion House DS0000001329.V256576.R01.S.doc Version 5.0 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 Champion House DS0000001329.V256576.R01.S.doc Version 5.0 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. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Champion House Address Clara Drive Calverley Yorkshire LS28 5PQ 01274 612459 01274 619221 mary.harrison@ney.leonardcheshire.org 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) Leonard Cheshire Mary Louise Harrison Care Home 26 Category(ies) of Physical disability (26) registration, with number of places Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 3/2/05 Brief Description of the Service: Champion House which is a converted extended stone built property, previously a mill owners wife’s house, provides care for service users between the ages of 18 and 65 all with physical disabilities. Care is provided on two floors in singly occupied rooms some of which are very spacious. The top floor of the home is used as a training area for staff. Each individual has their own private room decorated to their own personal taste, and which is provided with all necessary aids and adaptations to suit individual’s requirements. Every room is fitted with a nurse call facility. It is situated in a rural area of Leeds. Entry to the home is down a long driveway therefore providing privacy for the service users. It is close to both Bradford Town Centre, and Leeds City Centre. There are many shops, a Post Office and supermarkets close by, and a large retail park is only a short drive away. There are extensive gardens and a large car park. There are three lounge areas provided, one of which is dedicated to those service users who smoke. The home has a mini bus, which is used to take service users out on arranged visits, and also out on shopping trips. Meals are taken in the large dining area, which also doubles as an activities area when not being used for dining purposes. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over six hours by one inspector on 5th October 2005. The purpose of the inspection was to ensure the home was operating and being managed for the benefit and well being of the residents. Comment cards were taken to the home on the day of the inspection to give residents and relatives the opportunity to comment anonymously. It is expected that a number of these will be completed and returned. The inspection consisted of reviewing care documentation and staff files. Talking to residents and staff, and looking around the premises. Because of the detailed information package provided to prospective residents, they are able to make an informed choice whether or not to come to live at the home. Pre admission assessments ensure resident’s needs are assessed and documented. This assures their needs can be met once admitted. Care plan documentation is of a good standard providing staff with a tool by which they can ensure the residents needs, and any special needs are met. The medication system is safe, however it is advised that signatures are present on hand written instructions on MAR charts of medication prescribed out of the normal monthly cycle. Social activities are provided at the home, and residents said they enjoyed them. They also said they enjoyed the food, and preferred the main meal of the day at teatime. Staff continue to be provided with training with many of the staff achieving NVQ at level 2 and 3. Staff spoken to said they looked forward to the training offered, as it gave them a better insight into the care residents should have. What the service does well:
The home encourages independent lifestyles within a risk management framework. Residents are treated with respect and live in a homely
Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 6 environment. The home tailors admissions to meet the individual person’s needs and choices and they take as long as required. Residents have comprehensive care plans in place. Those that are able are involved in developing theirs. Their needs are clearly identified with the tasks staff need to do in order for these needs to be met. The plans are reviewed on a regular basis. Residents are also involved in the recruitment and selection process. Communication amongst the staff team is good, and all staff spoken to showed a good understanding of the residents’ needs, and adult protection issues. Staff, and residents said that they receive excellent support from the manager and are able to approach her if they have any concerns or worries. Residents said that they feel well cared for, and that staff treat them with respect at all times. There is a range of activities offered by the home and a new volunteer coordinator has recently been employed to work alongside the activities coordinator for fund raising purposes. The residents are encouraged to continue with their studies. Trips out and annual holidays abroad are organised, and risk assessments are in place as appropriate. Exchange visits with other Leonard Cheshire homes are also arranged. Residents are encouraged to maintain contact with family and friends and a cordless ‘phone is available for them to use if they need to. The local healthcare team offer good support to the residents and specialised services can be accessed if needed. There was evidence that the home is using a tissue viability assessment form in conjunction with, and developed by Leeds NHS Trust. There was also evidence that a Physiotherapy care plan has been put in place for residents. An excellent diet is offered at the home that includes plenty of fresh food. Training is a high priority, and staff said that they also have access to other relevant courses. 11 care staff have completed an NVQ (National Vocational Qualification) at level 2, others are working towards completing the award. One member of care staff has also completed level 3. The training co-ordinator provides late evening training for the night staff, and attends the home up to 10.30pm to ensure their training needs are met. . Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 7 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. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 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 Champion House DS0000001329.V256576.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 5 Future residents and their carers can be sure that the home will meet their needs and aspirations. Social and healthcare professionals have helped the residents choose this home. EVIDENCE: The home very rarely has any vacancies, however when this occurs, the home usually has some indication that there is a prospective client who might want to be admitted. The home undertakes a comprehensive pre-admission assessment for all residents. The home makes sure this is done by using an initial support plan developed by the foundation and used throughout all the registered establishments. The manager visits the future resident and carries out an assessment of need before agreeing the admission. The introductory period is tailored to meet the individual needs and the number and length of visits are very flexible. Information is provided for people to make an informed choice about the home prior to them being admitted. Each resident has an individual contract in their file that explains the terms and conditions of the service. This also includes the fees that are payable by the resident. It does not however contain details of what is to be paid for over and above what is not covered by the fees. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 10 Champion House DS0000001329.V256576.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 and 9. Good communication makes sure that the residents’ needs are met. Appropriate risk assessments with coping strategies are in place to support an independent lifestyle. EVIDENCE: All residents have a comprehensive, holistic care plan that gives information about their needs. Relatives and or residents are involved in drawing up the plans but they do not sign to say that they agree with them. The plans are reviewed and updated on a regular basis. Very comprehensive risk assessments with the relevant coping strategies are in place. Specific instructions were seen in the care plans about what the home needs to do to meet the residents’ needs. The residents’ rights are respected and this was seen throughout the inspection. Residents are also involved in the recruitment process. They are supported to follow their individual interests and appropriate risk assessments are in place detailing these. The nurse in charge, and staff showed a good
Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 12 awareness of residents’ right to take risks as well as their duty of care and are able to balance these. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 15, 16, and 17. Appropriate activities are arranged for residents. Residents are supported to keep contact with family and friends. The rights of the residents are respected at all times. EVIDENCE: Residents are supported to take part in valued activities such going to the pub and out for meals, visiting local attractions and doing the things they enjoy. On the day of the visit 5 of the residents had been taken to Fuengirola, with 5 care staff including the manager as support. Some of the residents attend local training centres The home operates an open house policy and friends and relations can visit whenever they wish. The staff provide assistance for relatives who are elderly and disabled parents to visit. One young man goes to his parents each weekend, and one parent stays at the home when she comes to visit. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 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. Residents receive individual support from the homes staff that is preferable to them. Their emotional and physical health needs are met. Staff administer all medication. EVIDENCE: Residents spoken to during the visit told the inspector that they had all the support they needed, and at times and in the way they preferred. There was evidence throughout the inspection that showed the residents are treated with respect and their dignity is maintained at all times. Personal support is given in the privacy of the resident’s own room or bathroom. Although the trained staff administer all the medication, the home has a self medication policy. If any resident decides they would like to take charge of their own medication, they would be allowed to do so following a satisfactory risk assessment. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 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. Residents and their representatives have their views listened to, taken seriously and action is taken to resolve any issues. Residents have their rights protected and are protected from abuse. EVIDENCE: The appropriate policies and procedures were seen to be in place. The training co-ordinator who is a Registered POVA trainer, confirmed that some of staff have had Adult Protection training. She is confident that staff are able to recognise the signs of abuse and know what to do if this happens. Care staff spoken to during the inspection showed an understanding of the different types of abuse, and said they would report anything they thought was abuse to the manager. One of the carers also said she knew she could contact the Police and the Commission. There is a complaints policy and procedure in place, a copy of which is displayed in the entrance hall. However it does not contain the timescales for the completion of the process. The nurse in charge said she was sure that residents and their relatives feel able to approach her or the staff if they have any concerns or worries. The residents spoken to confirmed these views. There is a Whistle Blowing policy in place at the home. Everyone is registered to vote and is able to use the postal system or go to the polling station. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 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): Standards 24 to 30 were inspected. The home offers a safe environment for the residents and provides them with suitable, well-maintained spacious accommodation. EVIDENCE: The home is suitable for its stated purpose and is well-maintained offering a safe comfortable environment to the residents. It is clean and tidy throughout with no offensive odours. There was evidence of recent redecoration. The communal rooms are very comfortable, offering sufficient space for everyone and there are ramps throughout the home to ensure easy access to all areas There is one area that residents can use if they wish to smoke. This area has ample fire protection, including fire blankets that are placed over resident’s legs. All residents have been provided with adjustable height beds, and there is electrical handling equipment installed in all the bathrooms, and in some of the resident’s rooms who require this level of care. The home was seen to be very clean, and with no unpleasant odours. Many of the rooms were furnished with pictures and other items of personal furniture.
Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 34 and 36 Staff are provided with mandatory training and other training relevant to the needs of the residents. Supervision is adequately addressed. Recruitment procedures are not robust and do not protect the resident. EVIDENCE: Staff spoken to on the day of the visit told the inspector that they were aware of the responsibilities of themselves and other members of the staff team, and that they were provided with supervision both formally, and on a daily basis. There was written evidence to support this. They also said they were provided with training, not only compulsory, but other training so that they could provide the residents with the care needs they had been assessed for. Recruitment documentation selected for inspection identified that relevant documentation was missing. There was no photo identification of the employee in two of the files. No evidence that the provider had undertaken CRB, and POVA checks in two of the files. The provider had accepted a CRB from a previous employer for one of the employees. There was also evidence to support the home had accepted references; however, not from the previous employer, in one of the files. All files however contained interview information. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 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, 38, 41, 42 and 43 The home is well managed, the interests of the residents are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: Although the manager was not present at the home, it was evident there is strong leadership at the home, with the manager being qualified and experienced in this field of work. She is a qualified nurse and has completed the work for the registered manager’s award. All records were properly maintained and safely store, and there was evidence that Policies and procedures are updated as required, some very recently. Residents every three months, and one of the residents is the spokesperson for the home. Residents told the inspector that they were aware they could have access to their records if they so choose. There was also evidence of staff supervision sessions, and written records are in place, and staff spoken to said that these take place as required six times per year.
Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 19 The home has an adequate Health and Safety Policy and all staff have received training in this area. Records of monthly inspections by the Health and Safety co-ordinator are forwarded to head office. There is a call system throughout the building. Written evidence was also available confirming that staff have manual handling training. Fire bells are tested weekly with regular fire practice sessions. Nothing was seen during the inspection that could cause a hazard to residents, visitors or staff. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 20 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x 3 3 2 Standard No 22 23 Score 3 4 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 4 3 x Standard No 24 25 26 27 28 29 30
STAFFING Score 4 4 4 4 4 4 4 LIFESTYLES Standard No Score 11 4 12 4 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 x 1 x 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Champion House Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x 3 3 3 DS0000001329.V256576.R01.S.doc Version 5.0 Page 21 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 *RQN Regulation 5 (1)(b) Requirement The Registered Provider must ensure that all residents are provided with a written costed terms and conditions of residency which contains details of what has to be paid for that is not covered by the fees. The Registered Provider must ensure that recruitment documentation contains all relevant information as contained within Schedule 2. Timescale for action 31/01/06 2 YA34 30/11/05 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 5 Good Practice Recommendations That all hand written entries on MAR charts are signed by the nurse making the entry. Champion House DS0000001329.V256576.R01.S.doc Version 5.0 Page 22 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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