Inspection on 26/07/05 for Elland Road

This inspection was carried out on 26th July 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Elland Road 20/04/09

Elland Road 24/04/07

Elland Road 09/02/06

Elland Road 30/12/04

Elland Road 15/06/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Snydale Care Home

Whitwood House

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

CARE HOME ADULTS 18-65 Elland Road 67 Elland Road Churwell Leeds LS27 7QS Lead Inspector Carol Haj-Najafi Announced 26 July 2005 th 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 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 Stationary 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. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Elland Road Address 67 Elland Road Churwell Leeds LS27 7QS Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0113 2526561 0113 2526561 Northern Life Care Ltd T/A U.B.U. Judith Wilson Care Home Only 7 Category(ies) of Learning Disability (7) Physical Disability (7) registration, with number of places Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 30th December 2004 Brief Description of the Service: Elland Road is in Churwell near Morley, Leeds. It is on a main bus route and has good access to local shops, including the White Rose centre and Morley shopping centre. The home provides 24 hour care to seven younger adults with a learning disability, some of whom also have a physical disability.The home has a dining room and two lounges, one lounge is spacious and used regularly by most service users, and the other is a smaller quiet area. The kitchen is domestic in character although service user access is limited. Six bedrooms have en-suite and are on the ground floor, one bedroom is on the first floor with easy access to a bathroom and toilet. There are three bathrooms, two which have assisted baths. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this announced inspection between 9.30am and 5.15pm. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. The inspector looked around the home, observed practice and spoke to one resident, a visitor, three staff, the deputy manager and the registered manager. Service users living at the home have very complex needs, and discussions with service users are very limited. Records were inspected including admission assessments, service user plans, risk assessments, daily records, staff training and recruitment records and some policies and procedures. What the service does well: What has improved since the last inspection? What they could do better: The manager needs to make sure that the listening devices that are used to monitor epilepsy do not compromise service user’s privacy and dignity. An assessment needs to be completed to make sure the devices are necessary, and if they are guidance should identify when they are used. An additional ceiling track hoist needs to be installed because the moving and handling equipment is not satisfactory in one room. When the home are recruiting staff they should check information more carefully. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 6 Extra information must be included in the adult protection procedure to make sure everyone is clear who would report any allegations of abuse. Requirements identified at this inspection can be found at the end of this report. 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. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 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 standard(s) 2, 3, 4 & 5 The home’s admission process is very good. Admissions are carefully planned, and consideration is given to the needs of prospective service users. Good consultation and assessments take place before service users move into the home. EVIDENCE: A service user was admitted to Elland Road earlier in the year; no other admissions have taken place for the last thirteen years. The evidence is therefore based on one admission. Several different assessments were completed, which included a comprehensive care management and occupational therapy (OT) assessment, and environmental equipment was installed to meet the recommendations from the OT assessment. The home obtained a lot of information from the service user’s family and day service and completed a very detailed assessment. An admission plan was drawn up which identified who should be involved and how many visits should be arranged. The service user visited the home many times before admission. The visits were recorded, and included looking around the home, having meals, meeting other service users and relatives, and over night stays. A review was held six weeks after the admission to confirm the placement was suitable. Service users are issued with a written contract on admission and when the cost of charges is updated service users are informed in writing. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 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 standard(s) 6, 7 & 9 Service user plans and risk assessments are very good, and are effective working documents, this has resulted in staff having a good understanding of what care is needed. A lot of decisions have to made on behalf of the service users although the home works very hard to involve service users and their families as much as possible. EVIDENCE: Two service user’s records were looked at. Service user plans were very specific, and clearly identified the support required to achieve the agreed outcome. Each service user plan was very individual and written using a person centred approach. Staff members were familiar with the plans and refer to them for guidance. Risk assessments are completed and action points are well defined. Individual plans are regularly reviewed and service users, relatives, staff and management are involved. When a risk or area of need is identified the appropriate assessment is completed. Some service users, who have epilepsy, have monitors (listening devices) in their bedroom, this is to alert night staff if they have seizures. During the inspection, a listening device was left on in one of the bedrooms, and discussions in the bedroom could be Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 10 heard in the lounge. A formal assessment should be completed to make sure a monitor is required, and then clear guidance on the use of monitors should be formalised to make sure the privacy and dignity of service users is not compromised. Staff talked about involving different people and using knowledge and experience in decision-making processes. A relative said they are consulted regularly and gave examples when ideas and suggestions have been discussed. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 11 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 standard(s) 12, 13, 14, 15 & 16 Service users receive an individually tailored care service, which consists of varied and frequent activities. Staff are active in promoting family relationships and make visitors feel very welcome when they visit the home. EVIDENCE: Staff talked about the recreation that service users enjoy; outings are very popular. Various in house activities are provided, one service user said she enjoyed having a foot spa. Daily records confirmed that regular outings and activities are arranged, and public transport is well used. On the day of the inspection two separate outings were taking place, one to a local shopping centre, and one to a nearby town using the train. Different day care arrangements are in place, some service users attend external day care services, others receive activities through the home. Service users likes and dislikes, and suggestions for activities are recorded. Service users have a lot of photographs displayed in their rooms. Staff spoke of spending time looking at pictures and talking about family and friends. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 12 One relative said she was impressed with the home and was always made very welcome when she visited. Staff keep in regular contact and will ring if there or any problems or to say things are going well. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19 Healthcare needs are appropriately met. EVIDENCE: Keyworkers monitor health care needs as part of the reviewing process, and arrange any necessary appointments. All healthcare appointments and contacts are recorded. Service users have regular dental and chiropody appointments, and specialist consultants are involved where appropriate. Information relating to specific medical conditions and assessments to identify and monitor health care needs were available in service users files. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 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 standard(s) 22 & 23 Although service users are generally unable to say how they are feeling, staff try hard to interpret their wishes through other methods. Service users are safeguarded from abuse but further confirmation is required to ensure any allegations of abuse are appropriately reported. EVIDENCE: Service users are generally not able to say if they are satisfied with the service. Staff spoke about observing service users, and using knowledge and experience to identify when service users are unhappy. Service user plans have information which indicates when someone is unhappy or in pain. No complaints have been received during the past twelve months. The home has a complaints procedure. The home has adult protection policies and procedures, although responsibility for reporting and liaising with other agencies is not clear. The manager was unsure who would take on this responsibility. Staff have attended adult protection training. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 & 30 Elland Road is homely, and nicely decorated and furnished. It is very clean and well organised. Service users have lovely personalised rooms. Specialist equipment has been obtained to meet individual needs, although one service user is waiting to have a ceiling track hoist installed. EVIDENCE: The inspector looked around the home and everywhere was clean and tidy. Bedrooms are very personal, and careful consideration has been given to the décor to ensure it reflects the preferences of service users. One service user had an excellent sensory board that has been designed by staff. A lot of different equipment was available to help maintain skills and promote independence. A moving and handling assessment has recommended that a ceiling track hoist should be provided for one service user; the manager said negotiations are taking place regarding funding. This was identified as a requirement at the last inspection. The furnishings, carpets, and furniture are good quality and the home is decorated to a high standard. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 16 Everyone spoken to during the inspection said the environment was always clean and tidy. The manager said the home has met the requirements from the last environmental health and fire service visits. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31, 32, 33, 34, 35 & 36 Staff have a good understanding of the needs of service users and there is good team work. Staff benefit from regular staff meetings, supervision and training courses, and have worked hard to achieve NVQ awards. The home is adequately staffed. Tippex should not be used on staff rotas, as this prevents alterations from being properly monitored. Some recruitment records were not available, therefore it cannot be assured that service user’s are safeguarded by the home’s recruitment process. EVIDENCE: The inspector spoke individually to five staff including management. Everyone said they thought the home provided a good standard of care. Staff had a good understanding of service user’s needs, daily routines, keyworker responsibilities, and the different roles of team members. Guidelines and checklists for routines and staff responsibilities are in place. Staff rotas were looked at; tippex had been used when changes had been made. The home has a minimum of four members of staff on duty for each day shift and two waking night staff, often five staff are on duty during the day. Staff have attended training courses which cover health and safety areas and good care practice; these include, working safely, load management, fire safety and first aid and person centred planning; 5 staff have completed NVQ level 2 and 8 are in the process of completing. Individual training records and the team training plan was looked at. The manager has identified training for Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 18 three staff which has expired; the appropriate training has been booked. All new staff complete an induction programme that includes LDAF (Learning Disability Award Framework) training. The management team discussed the recruitment process, which includes analysing application forms, references and CRB disclosures (police checks) and conducting interviews. The manager said they had seen the recruitment records for the most recent recruit but the documentation was not available in the home. Proof of identification, two references, an application form, a CRB, and an interview assessment had been obtained for another recent employee, however, the application form did not contain specific dates for previous employment. Staff receive monthly supervision, and attend monthly staff meetings. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 40, 41 & 42 Recording systems are good. The health and safety of service users and staff are protected. EVIDENCE: Records contain good information and they are stored securely. The pre inspection questionnaire confirmed that policies and procedures are available and regular maintenance and health and safety checks are completed at the home. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 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 4 4 4 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 2 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 x Standard No 31 32 33 34 35 36 Score 3 3 3 2 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Elland Road Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x x 3 3 3 x J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 21 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 YA7 Regulation 12 Requirement The registered manager must formally assess the use of listening devices, and ensure guidance is introduced to ensure privacy and dignity is not compromised. The registered provider must ensure the adult protection procedure clearly identifies who is responsible for reporting allegations of abuse to other agencies. The registered provider must provide staff with additional moving and handling equipment to meet the needs of the service user identified (timescale of Februaury 2005 not met). The registered provider must ensure any gaps in employment are explored, and make available for inspection all recruitment documentation. Timescale for action 30th September 2005 2. YA23 13 30th September 2005 3. YA 29 23 30th November 2005 4. YA34 19 30th September 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 22 No. 1. Refer to Standard Good Practice Recommendations Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 Page 23 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 Elland Road J52 S1447 Elland Road V183111 260705 Stage 4.doc Version 1.40 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. 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!