Inspection on 26/09/06 for Cleveland Road

This inspection was carried out on 26th September 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cleveland Road 01/02/06

Cleveland Road 27/02/05

Cleveland Road 04/11/04

Cleveland Road 13/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Cleveland Road 5 Cleveland Road Edgerton Huddersfield West Yorkshire HD1 4PP Lead Inspector Karen Summers Unannounced Inspection 26th September 2006 09:00 Cleveland Road DS0000026323.V300810.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 Cleveland Road DS0000026323.V300810.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. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cleveland Road Address 5 Cleveland Road Edgerton Huddersfield West Yorkshire HD1 4PP 01484 515865 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) Bridgewood Trust Limited Mr Earle Michael Keating Care Home 13 Category(ies) of Learning disability (13) registration, with number of places Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 1st February 2006 Brief Description of the Service: Cleveland Road is owned and managed by Bridgewood Trust, and it is an organisation that specialises in providing accommodation for adults with a learning disability. The home is registered to provide accommodation and care for up to thirteen service users, and all bedrooms are for single occupancy. The establishment is a Victorian property and is situated in a residential area, close to the town centre of Huddersfield. The property is spacious and well maintained throughout, and is indistinguishable from neighbouring houses. All the service users live active and varied lifestyles and are encouraged and enabled to participate in all aspects of daily living activities. Fees at the home start at £362 - £866.78 week. Items not covered by fees include: Toiletries, outings and holidays. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report refers to a key inspection, which included an unannounced site visit on the 26 September 2006, and the duration of the inspection was 6.75 hours. There were 2 service users in residence on the day. Mr Earle Keating, manager, was present throughout the inspection. The following areas were looked at and have been used in the production of this report; a sample of records, care plans, medication, individual discussion with service users, two members of staff, tour of the premises and document reading. To reflect the views of those who use the service, satisfaction questionnaires were sent to: 10 service users, none were returned; 10 relatives/ advocate/ friend, 2 were returned, and GP’s and district nurses, none were returned. The inspector would like to thank those who contributed to the inspection process, and also thank Mr Earle Keating, his staff and service users, for their time and hospitality on the day of inspection. What the service does well: What has improved since the last inspection? The care records are now written in ink not pencil, and the information recorded in the service users plan, and risk assessments have improved. 50 of care staff have an NVQ level 2. Staff have had a fire lecture and a further lecture has been booked for the 26th September 2006. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 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. Cleveland Road DS0000026323.V300810.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 Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2,3 & 5 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. No service user moves into the home without having had his/ her needs assessed and been assured that those needs will be met. Prospective service users have an opportunity to visit and assess the quality, facilities and suitability of the home. Each service user has a contract of terms and conditions with the home. EVIDENCE: Prior to admission prospective service users are invited for tea, and then if appropriate progress to overnight stays. This enables them to see how life is at the home, and also enables staff to carry out a full assessment of their needs and ensure that those needs can be met at Cleveland Road. Once the manager was satisfied that they could meet the service users needs then they would be offered a place at the home. Each service user has an individual contract of terms and conditions with the home. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users personal and social care needs are set out in an individual plan. They make decisions about their lives with assistance as needed, and are supported to take risks as part of an independent lifestyle. EVIDENCE: The care documentation was changed earlier in the year to include a comprehensive assessment of the service users needs, and the service user helped to complete the record. The documentation is further being developed and not all the records had been completed due to holidays and sickness. The manager said that the documentation would be changed to the new system within the next 3 months. Risk assessments have been used to document any potential risk for a service user, and there was evidence that the documentation had been reviewed. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 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): 12,13,15,16 & 17 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users take part in appropriate activities, and are part of the local community. Service users are encouraged to maintain contact with their family and friends. Service users receive a varied diet that takes into account their likes/ dislikes and dietary needs. EVIDENCE: Service users participate in a wide range of social and recreational activities, and are also encouraged to develop and maintain independent living skills. Monday to Friday service users attend a number of community activities that include; The Bridgewood Trust horticulture centre, a craft centre, and a college and resource centre. Service users spoke of how they had enjoyed a recent birthday celebration of a service user from another of the Bridgewood Trust Homes. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 11 Service users were relaxed, and looked well cared for, and staff were observed supporting people in a caring and sensitive manner. One of the service users said that she was happy living at the home, and that the staff took care of her. Relatives’ questionnaires said that they were satisfied with the overall care provided, and one relative said that they were more that satisfied. The menu was varied and took into consideration special diets, and the likes and dislikes of service users. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 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): 18,19 & 20 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. Until staff record the outcome of the care/ support given to the service users there is no evidence to suggest that their needs have been met. Unless the procedures in relation to the updating of medication records is reviewed, there is a potential risk to service users. EVIDENCE: Please also refer to standard 6 regarding care records. The care records were a good standard, and included the personal support that the service user receives, and there was evidence to suggest that the documents had been reviewed and updated. The daily record however, should be written in more detail, as at the present time numbers are used to refer to the goals/ needs, and there is no evidence to show what care/ support has been given each day. The documentation should also be dated and signed by the author. Generally the medication housekeeping was of a good standard. The administration of controlled drugs was been recorded in the controlled drug register only, and not on the administration record. The administration of controlled drugs must be recorded on both records. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 13 To avoid a potential error in administration, where there is a change in the dosage of a drug, the instructions should be rewritten on the medicines administration sheet. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. Service users and their relatives can be confident that their complaints will be listened to, taken seriously and acted upon. Service users are protected from abuse. EVIDENCE: The complaints procedure continues to meet the standards. It is located in the service users guide and is written both in “Widget” and word format. Two staff have been booked on an update, Abuse Awareness course, and the remaining staff have had the training. There is also an adult protection procedure, which includes a whistle blowing policy. The home needs to have a more up to date Kirklees Protection of Vulnerable Adults Policy. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 15 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 & 30 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The home is in a good state of repair and decorative condition, and service users’ individual needs are met in a comfortable and homely setting. The premises are clean and systems are in place to control the spread of infection. EVIDENCE: The home remains well decorated and refurbished, and there was evidence to suggest that the maintenance to the property is carried out in a timely fashion. Aids and adaptation were in use around the home to maintain the independence of service users. The kitchen is to be refurbished within the next financial year, when the service users are away on holiday and this will ensure that there is as little disruption as possible. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 16 The premises were clean and systems are in place to control the spread of infection. Cleveland Road DS0000026323.V300810.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 Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. The staffing levels and skill mix were sufficient to meet the number and needs of service users, and appropriately trained staff supports service users. Service users are supported and protected by the home’s recruitment practices. EVIDENCE: There was a sufficient number and skill mix of staff on duty to care for the number of service users in the home. A questionnaire received from a relative said that in their opinion there were not always sufficient numbers of staff on duty. 50 of care staff have achieved an NVQ level 2 or equivalent. In relation to recruitment, the staff files contained the relevant information and documentation. Cleveland Road DS0000026323.V300810.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 & 42 Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. The registered manager is of good character and competent to manage the home. In relation to the views of the service users, they can be confident that the home is run in their best interest. Without all staff having up to date movement and handling training, staff and service users could potentially be at risk of being injured. EVIDENCE: Mr Earle Keating, the manager, has a number of year experience in the care of people who have learning disabilities, and he has almost completed an NVQ level 4 in management and care. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 19 Prior to the service users six monthly review, they are assisted by either a manager from another home, or an advocate to complete a satisfaction questionnaire. The questionnaire is then discussed and any appropriate action taken. The company has attained a quality of assurance certificate of registration for ISOQ001. Fire alarms and emergency lighting are tested/ checked each week and records are kept, and all staff have two fire lectures and drills each year. In relation to movement and handling, the training records showed that not all staff had had up date training, and there were service users who have movement and handling needs. (Depending on the risk assessments of the service users, all staff should have movement and handling updates annually.) Mr Keating confirmed that he would arrange update training for all the staff to go to. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 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 Standard No Score 1 X 2 3 3 3 4 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 2 1 X 2 X 3 X X 1 X Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 21 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 YA20 Regulation 13.- (2) Requirement Timescale for action 23/10/06 2. YA42 13.-(5) “The registered person shall make arrangements for the recording, handling, safe keeping, safe administration ad disposal of medicines received into the care home.” The registered person shall confirm in writing by 23/10/06 that this now takes place. 23/10/06 “The registered person shall make suitable arrangements to provide a safe system for moving and handling service users.” All staff must have movement and handling training. The registered person must confirm in writing by 23/10/06 that training dates have been arranged. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 22 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. 2. 3. 4. 5. Refer to Standard YA6 YA18 YA19 YA23 YA37 YA42 Good Practice Recommendations Care documentation should be dated and signed by the author. The daily record should show the outcome of the planned care/ support/ behavioural management etc., and how the carer has honoured their duty of care. The Kirklees Protection of Vulnerable Adults Policy should be replaced with up to date documentation. Standard 37.2 - The manager should have an NVQ level 4 in management and care or equivalent. Depending on the risk assessments of the service users, all staff should have annual movement and handling training. Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB 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 Cleveland Road DS0000026323.V300810.R01.S.doc Version 5.2 Page 24 - 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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