Inspection on 26/01/07 for Cuthbert Close

This inspection was carried out on 26th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cuthbert Close 06/01/09

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Muston Road (70)

Grayling

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

CARE HOME ADULTS 18-65 Cuthbert Close 1/2 Cuthbert Close Queensbury Bradford West Yorkshire BD13 2DF Lead Inspector Pamela Cunningham Key Unannounced Inspection 26th January 2007 10:45 Cuthbert Close DS0000068491.V314022.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 Cuthbert Close DS0000068491.V314022.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. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cuthbert Close Address 1/2 Cuthbert Close Queensbury Bradford West Yorkshire BD13 2DF 01325 373700 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) Saint John of God Care Services Mr Kenneth Beaumont Hillyard Care Home 12 Category(ies) of Learning disability (12), Learning disability over registration, with number 65 years of age (12) of places Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 26th January 2006 Brief Description of the Service: 1 & 2 Cuthbert Close is made up of two bungalows each with six single bedrooms offering nursing care and support for people with learning and physical disabilities. The bungalows, which are purpose built and designed and equipped to a high specification, are located within the community of Queensbury, which is ideally situated, having easy access to all facilities within Bradford, and is only a few miles from open countryside. The buildings are well maintained externally. It is situated in a quiet residential area, and is surrounded by well-tended gardens. The home has a mini bus, which has tail lifts to enable the wheelchair bound service users to use the transport facilities and take them on organised outings. 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 assessed requirements. Every room is fitted with a nurse call facility. In each of the bungalows the service users share the communal lounge, dining room and patio areas. All service users have access to local day care activities according to their abilities and individual needs. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit was made on 26th January 2007. The home did not know that this was going to happen. Feedback was given to the manager at the end of the visit. This was the first visit since 26th January 2006. The purpose of this visit was to look at what improvements had been made and make sure that the home was being managed for the benefit and well being of the clients. Information had been asked for before the inspection, about what policies and procedures are in place, when they were last reviewed, when maintenance and safety checks were carried out and by who, menus used, and staff details and training provided. All information required was returned before the inspection took place. Visitors’ comment cards were sent to the home before the inspection took place thereby giving the opportunity for anonymous feedback but only one was returned, therefore it was difficult to gain any information from relatives about the care provided as there were none on the premises at the time of the visit. One of them made a statement regarding the home not having enough staff on duty, but staffing was found to be adequate to meet the needs of the clients on the day of the visit. Comments cards for the clients are not forwarded to the home because of their lack of understanding. During the visit clients’ and staff were spoken to. Other records in the home were looked at such as staff files, policies and procedures, complaints and accidents records. The scale of charges for care provided on the day of the inspection was between £850 and £1150 per week. What the service does well: The staff are committed and caring people and create a warm homely atmosphere that appears to be appreciated by clients. Relationships are good and only a couple however able to raise any concerns they might have, this is not detrimental to their care, as all the staff have worked at the home for a Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 6 long time and know the clients well. The needs of clients’ are assessed on an ongoing basis and their personal goals identified. The care plans provide clear and detailed instruction for staff to follow and the details of the plan are discussed and agreed with relatives during 6 monthly reviews. Clients receive personal support in a way that it is hoped they would agree with, if it were possible to discuss this with them. Clients’ rooms are personalised with their own belongings and they are included and have a choice about spending time in their bedroom or in communal areas. Certain residents said they like the food that is provided. Training takes a high priority in the organisation that operates the home and staff said that they are able to access training courses that will better help them understand the needs of their clients. They are given time to work on NVQ (National Vocational Qualifications) and all of the staff are involved in these at varying stages and levels. What has improved since the last inspection? What they could do better: Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 7 Certain records relating to Health and Safety could be made available and kept on the premises for the purpose of inspection, and staff need to be more vigilant in reporting to the manager, any areas of concerns that might compromise the safety of the clients. 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. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 4 and 5. Quality in this outcome is good. This decision was made through looking at all available evidence, and a visit to the home People are assessed prior to admission, and have enough information to make a decision whether or not to come to live at the home. EVIDENCE: The Statement of Purpose and Service User Guide is a comprehensive well put together document that is given to all prospective clients and relatives. This makes sure they have all the information they need to make up their mind if the home is suitable and can meet their needs. Pre admission assessments take place and provide enough information for the home to prescribe a suitable care package. Prior to admissions taking place the clients are assessed by an initial panel of three people, consisting of the Area Manager, the manager for the home and one other. Preliminary risk assessments are done in this early stage. Referrals are made via Social Services, the Learning Disability Trust and privately by parents/carers. There is a three months trial period during which time contracts are drawn up with various funding authorities, and which also gives the clients time to settle in, and for the existing clients to get to know them. Contracts are finalised within the three months trial period. Cuthbert Close DS0000068491.V314022.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 these outcomes is excellent. This decision was made through looking at all available evidence, and a visit to the home. It is very difficult to make sure clients know their needs are reflected in their individual plans due to lack of cognitive skills. They are allowed to take risks as part of a risk management programme EVIDENCE: Due to the cognitive problems the client group present with, it is difficult for the staff to be sure the clients are aware their needs are reflected in their care plans. To overcome this, 6 monthly reviews are held, to which parents/carers are invited. It is at these reviews, and changes in health needs are discussed and agreed on. As a general statement, clients living at Cuthbert’s’ Close have complex needs and the care plans need to be very detailed to make sure that the staff are able to meet those needs. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 11 Two sets of care plan documentation (Individual Life Plans, or the get to know me documentation) were looked at. In both documents there was excellent information regarding medical history, which is important with this type of client, as they are unable to voice their concerns. The care plans also contain a list of all current medication with possible side effects. Death and dying is well documented, but it is difficult to discuss with the client, and more so if a close member of the family dies. Consent to treatment is well documented and there is excellent information in the ILP’s about the clients’ rights and how they should be treated. All risk assessments were present where a risk to the client had been identified. Care plans are reviewed at least every three months, or when there is a recognised need, and a daily record of care given is also written. Currently the care plan documentation is of a level that represents good practice. Cuthbert Close DS0000068491.V314022.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): 12,13, 14, 16 and 17 Quality in these outcomes is excellent. This decision was made through looking at all available evidence, and a visit to the home. Clients are encouraged to join in social and leisure activities, to maintain links with their friends and family and to exercise choice and control over their lives. They are offered a good varied and nutritious diet that takes account of individual dietary and care needs. EVIDENCE: Two Clients, who were able to speak to me, said they enjoy meals and mealtimes, and are able make drinks under the direct supervision of staff. All appropriate risk assessments are in place, with the exception of one discussed earlier in the report. The menu is developed in conjunction with the community dietician. The care plans showed evidence of good dietary intake, with regular weight checks. There are a variety of special dietary needs that are catered for. Meals are taken in the dining area, and are prepared by the designated carer. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 13 Menus are four weekly and rotational with a brunch being served on weekend days as many of the clients like a lie in. This is good practice Meals are very substantial and fresh fruit and vegetables are always used. The kitchen was clean and well organised with records kept of core food and fridge and freezer temperatures. The nurse in charge confirmed the dietician was still involved with menu planning. Food was stored correctly in the fridge, but the seal on the freezer is split, and either needs renewing or a new freezer buying. The nurse in charge told me that some of the clients have day care, however due to the amalgamation of the Trust and Social Services, funding issues have been raised and day care is now provided only minimally. It has therefore fallen to the staff to provide leisure activities, which mainly means clients are taken out shopping or for meals out. All clients have a holiday either abroad or in the UK unless there is a special reason, and staff that are willing, go with them as escort. Family involvement is seen as very important. Cuthbert Close DS0000068491.V314022.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 these outcomes is good. This decision was made through looking at all available evidence, and a visit to the home. Clients receive personal support in the way they prefer, and their physical and emotional needs are met. EVIDENCE: All clients are cared for by their key worker who is a carer who has been chosen to care for a particular client. Personal care is given either in the client’s own rooms, bathrooms or toilets. Spiritual needs are cared for by visiting clergy, or by the Brothers of the Order. Staff spoken to said it was difficult to make sure care was delivered in the way the client prefers, but as they have worked at the home for along time, they know their clients well and can immediately tell by the way they react if they are not pleased or are unhappy with something. At the time of the visit there were no clients who were capable of managing their own medication, this is managed on their behalf by the qualified nursing staff, and is documented. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 15 As described earlier on in the report, Death and dying is well documented, but it is difficult to discuss with the client because of their lack of understanding. It is more difficult to manage if a close member of a client’s family dies. The service uses a monitored dosage system of medication control. All clients receive their prescribed medicine directly from a dossette box prepared by the pharmacist who supplies the home. The system was inspected and was found to be safe. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 16 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 these outcomes is excellent. This decision was made through looking at all available evidence, and a visit to the home. Clients are protected from abuse, neglect and self-harm, and their views are recognised. EVIDENCE: The home has a complaints procedure in place that includes the timescales for the completion of the process. The nurse in charge said she feels confident that relatives will speak to her, the service manager or the staff if they have any concerns. There is also a pictorial version of the procedure with clear symbols the clients are able to recognise. There have been no complaints since the last inspection. Recruitment documentation was inspected. The recruitment process is robust and protects the clients. Documentation seen were complete with interview notes and any supervision notes. All staff have training in abuse awareness. It is mandatory and carried out annually. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 17 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): All standards were assessed. Quality in these outcomes is excellent. This decision was made through looking at all available evidence, and a visit to the home. The home offers a safe, well-maintained environment for the residents and provides appropriate bathing and toilet facilities with work on the environment is continually taking place, and to a high standard. EVIDENCE: The home continues to offer a very comfortable, homely environment with the fixtures and fittings being of a very high standard. It was found to be very clean, tidy and hygienic throughout. All of the bedrooms have en-suite facilities and specialist equipment is available ensuring the safety of residents and staff. It was clear a great deal of thought continues to be put into the individual bedrooms ensuring that they suit the residents’ needs, wishes and choices Communal areas are nicely furnished and offer comfort and safety to the residents. Assisted bathing facilities are available for the residents in both bathrooms including a shower trolley, and overhead tracking is in place in some Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 18 bedrooms. Light and sound equipment is also present in some of the bedrooms. The home is clean and hygienic throughout. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 19 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 and 35 Quality in these outcomes is good. This decision was made through looking at all available evidence, and a visit to the home. Clients are supported and protected by the recruitment procedures in place. Staffing numbers make sure that the clients’ needs continue to be met. EVIDENCE: The nurse in charge said that the clients benefit from the clearness of staff roles and responsibilities. Clients recognise the grades of staff by the tasks they perform. One client when asked who ”the boss was” quite clearly gave the name of the manager. Staff rotas showed that there are usually enough people on duty at the home and this was seen at the inspection. Staffing is stable with many of the staff having been employed since the home was first registered. All staff receive induction and mandatory training (Fire Safety and Manual Handling) and many of the staff are working on or have completed NVQ at different levels. Staff are also provided with LDAF (Learning Disability Award Framework) training in order that they are trained to meet the complex needs of the residents. Qualified staff are able to continue with their PREP. Staff are delegated responsibility for specific tasks. Members of staff spoken to at the inspection Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 20 said that they receive good support from the manager. Staff spoken to said they receive formal supervision every four weeks. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 21 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): All standards were assessed Quality in these outcomes is good. This decision was made through looking at all available evidence, and a visit to the home. The home is well managed, the interests of the clients are seen as important to the manager and staff and are safeguarded at all times. EVIDENCE: The manager continues to offer good strong leadership and is well qualified and experienced in this type and area of work. This is shown by the home running as well when he is absent. Records seen were correctly maintained and stored. Clients and their families are made aware of their rights to see their records. Clients, who are able, participate in all aspects in the running of the home, and whenever there is a review of care held the residents and their families are invited. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 22 Health and Safety records were seen and were up to date with the exception of the records for the testing of the portable appliances, which were unavailable. The manager needs to provide proof that these tests are taking place, as non of the portable appliances seen had PAT stickers on. All policies and procedures sampled were up to date and had been reviewed within the last twelve months. There is no reason to believe the accounts management of the home is not robust as the home is part of a not for profit making organisation who send end of year accounts to the Commission annually. Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 23 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 4 2 3 3 4 4 4 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 4 ENVIRONMENT Standard No Score 24 4 25 4 26 4 27 4 28 4 29 4 30 4 STAFFING Standard No Score 31 x 32 3 33 x 34 4 35 4 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 4 13 4 14 4 15 4 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 3 3 x 4 4 3 4 4 2 4 Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 24 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 YA17 Regulation 12(1)(a) Requirement The registered provider must ensure the fridge freezer in the kitchen in bungalow 1 is either provided with new seals, or is replaced. The registered provider must forward to the Commission documentary evidence that portable appliances are tested for safety annually. Timescale for action 01/04/07 2 YA42 12(1)(a) 01/04/07 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 Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 25 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 Cuthbert Close DS0000068491.V314022.R01.S.doc Version 5.2 Page 26 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!