Inspection on 09/02/06 for Elland Road

This inspection was carried out on 9th February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 1 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 26/07/05

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 West Yorkshire LS27 7QS Lead Inspector Carol Haj-Najafi Unannounced Inspection 9th February 2006 10:00 Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elland Road Address 67 Elland Road Churwell Leeds West Yorkshire LS27 7QS 0113 252 6561 0113 252 6561 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) Northern Life Care Limited T/A U.B.U. Judith Wilson Care Home 7 Category(ies) of Learning disability (7), Physical disability (7) registration, with number of places Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th July 2005 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 DS0000001447.V273945.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection over two days. The first was 10.00am to 12.30pm and the second day was 10.30am to 12.15pm The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. The inspector spoke to three staff and the registered manager. Service users living at the home have complex needs, and discussions with service users were very limited. Interaction between staff and service users was observed. Records were inspected including service user plans, risk assessments, daily records and recruitment records. Feedback was given to the registered manager at the end of the inspection. CSCI investigated a complaint in October 2005, a brief summary of the complaint is contained in the main body of the report. What the service does well: What has improved since the last inspection? What they could do better: Medication systems are well organised and staff have completed medication training but the records need to include more information about the medicines that have been prescribed. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 6 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 DS0000001447.V273945.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not looked at during this inspection. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not looked at during this inspection. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 17 Menus and meals are well planned and food records are good. EVIDENCE: Staff said the quality of meals were good. Menus are drawn up every four weeks. The person responsible for co-ordinating the menu has worked with a dietician to establish what makes a healthy diet plan. The current menu was varied and meal contents were nutritious. Any variations to the menus were recorded. Daily records contained information about what service users had to eat. Staff were able to confirm service users’ preferences and dislikes, these were also recorded in each service user plan (this is referred to as a service specification at the home). Staff are responsible for food shopping and cooking. All staff have completed the food hygiene course. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 11 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 & 20 Service users receive good, consistent care which is specific to their needs and preferences. Communication is good. Staff are trained and confident in administering medication but the administration records require more information. EVIDENCE: Service user plans contain very specific information about how service users prefer to receive personal support. Three plans were looked at and all were very individual. All staff were able to confirm that they referred to the service user plans for clarification and monthly staff meetings provided opportunities to discuss new ideas and ensure care is consistent. Staff also confirmed that new staff are instructed on induction how they must work with each service user. The home has a monitored dosage system for medication. Each shift has a designated person who is responsible for administering medicines. Medication storage is well organised although there was a large stock of 264 paracetamol tablets for one service user. Medication administration records were looked at and these had been signed correctly when medication had been administered. A monthly medication sheet is used for each service user, these are hand Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 12 written by staff. The medication guidance that is kept at the front of the medicines file states that two staff should check the entries but there was no evidence that this practice is done. The name and dose of each medicine is recorded but there is no additional information, for example ‘take with food’. Currently there is no system for recording on the medication sheet reasons why medication has not been administered. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are safeguarded from abuse. EVIDENCE: The CSCI investigated a complaint in October 2005. The complaint was divided into five elements. Four elements of the complaint were not upheld and clear evidence was gathered to support these outcomes. However, one element of the complaint was upheld; this related to staff recruitment. The home has taken steps to address the shortfall that was identified during the complaint investigation. Staff have attended adult protection training with the local authority adult protection unit. The manager is responsible for liaising and reporting concerns to the adult protection unit. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 29 The new lifting equipment has improved moving techniques for the service user. EVIDENCE: Since the last inspection, overhead tracking has been fitted to one service user’s bedroom. Staff confirmed this has improved the safety and comfort for the service user during hoisting. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 Staff only start work at the home after they have gone through a satisfactory recruitment process. EVIDENCE: The staff team went through an unsettled period around the time of the complaint investigation. Staff said that since then staff morale and teamwork had improved and the team were working well together. Recruitment records for two staff were looked at. All the necessary documentation was available, including interview assessments, references, criminal records checks, proof of identity and application forms. The manager discussed the recruitment process which includes an introduction to service users and staff, and an interview with the manager and deputy. One staff that started work within the last six months confirmed she went through a thorough recruitment and induction process. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 The registered manager is qualified and competent to run the home. The home has adequate systems for monitoring quality assurance. The new computerised records should be effective once everyone is confident in using the system. EVIDENCE: The manager is a registered nurse and has completed NVQ management level 4. She has regularly updated her knowledge through training and development meetings within the last year. Staff have a good knowledge of service users and consistently talked about observation as a key to establish service users satisfaction. They spoke about service user’s reviews and staff meetings which also provide opportunities to discuss service quality. The registered provider carries out monthly audits and these involve consultation with staff. A service business plan (for the home) identifies areas of development; the manager and the organisation monitor progress. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 17 A new computerised recording system has been introduced. This is relatively new and staff thought this could be a positive system but they had experienced some ‘teething problems’ and it has been time consuming putting all the daily information into the computer. On the day of the inspection, due to a password problem, staff could not access the computer until the manager arrived, therefore, they did not have access to some service user records. This was a reoccurring problem. General problems with the new system should be closely monitored. The daily records, hand written and computerised are very informative. Staff have recorded sufficient information to get an overall picture of what each service user has been doing. Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 3 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 4 X 2 X 3 X 4 X X X X Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 19 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 YA20 Regulation 13 Requirement The registered manager must ensure the medication administration records contain all the relevant information. Hand written charts should be referenced to the original prescription and checked by two staff, and reasons why medication has not been administered must be recorded. The stock of tablets should be monitored to make sure it is not excessive. Timescale for action 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Elland Road DS0000001447.V273945.R01.S.doc Version 5.1 Page 20 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 DS0000001447.V273945.R01.S.doc Version 5.1 Page 21 - 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!