Inspection on 26/04/05 for Fairfax Road

This inspection was carried out on 26th April 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Fairfax Road 26/02/09

Fairfax Road 23/03/07

Fairfax Road 28/10/05

Fairfax Road 14/12/04

Fairfax Road 27/09/04

Fairfax Road 23/03/04

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 Fairfax Road 19 Fairfax Road Leeds West Yorkshire LS11 8SY Lead Inspector Hebrew Rawlins Unannounced 26 April 2005 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. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Fairfax Road Address 19 Fairfax Road, Leeds, West Yorkshire, LS11 8SY 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 2778842 0113 2778842 Milbury Care Services Limited Mrs Linda Payne-Uttley Care home only 4 Category(ies) of Learning Disability 4), Learning Disability over registration, with number 65 years (4) of places Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 14 December 2004 Brief Description of the Service: 19 Fairfax Road is situated at the end of a quiet cul de sac but within 2 miles of Leeds City Centre. There are a wide range of shops and leisure facilities within easy reach of the property. The home is a 4 bed roomed detached bungalow with a carport and large garden. The bedrooms are all single rooms with washbasins and decorated to individual taste and choice. Residents are encouraged to buy personal items for their own use, which helps to create a comfortable atmosphere within the home. There is a lounge and open plan kitchen/dining room allowing service users to choose either to participate in or to observe domestic activity within the home. There is a bathroom and separate shower room. There is also a separate laundry room. Residents are encouraged to make full use of the entire house and garden and the facilities within, including the television as well as video and music systems. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection carried out on the 26th April 2005 at 11.00am by one inspector. The purpose of the inspection was to ensure the home continues to provide a good standard of care for its residents. Service users and staff present at the visit were made aware of the inspection through discussion with the inspector. They were invited to give their views on the care and services provided. Records were inspected and these included each resident’s care plans and staff recruitment files. What the service does well: What has improved since the last inspection? What they could do better: Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 6 More work is required on care plans to incorporate more risk assessment information regarding residents. Formal staff supervision should also be in place which would enable staff to receive direct feedback about their work and discuss any concerns they may\may not have. 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. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 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 Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 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) 1, 2, 3, 4, and 5 The home produces up to date written information for residents and relatives about the home. This enables residents, relatives and friends to know their rights and obligations at Fairfax Road. The home only admits a resident when a proper assessment has been undertaken. As much information as possible is obtained from health, social services and family about the care needs of residents before and on admission to the home. EVIDENCE: Statements of terms and conditions are available in each resident file. However residents were unable to say if these have been discussed with them because of their disability. The manager confirmed that pre admission assessments are always completed before any resident moves into the home. This was evident from information in resident’s files. The care plans had up to date information from external professionals, which enable the home’s staff to complete a relevant plan of care for residents. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 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) 6,7,8,9, Because of residents communication and sometimes-physical disabilities staff help resident choices by skilled observation. The care planning system continues to improve but more is needed in care plans and risk assessment. EVIDENCE: Through case tracking care plans were examined and their use was also discussed with the manager. It was seen that one resident was aggressive. This was not identified in the care plan or staff instructions given. Staff have a good knowledge of the residents and described different ways in which residents are assisted. The manager is the main person that completes the care plans and the care plans do not always contain adequate information and sufficient detail about the risk involved in working with people who have specialist needs. All resident care plans contained a photo of the resident and health needs. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,16,17 Staff recognises that time and support for residents outside the home is an important part of their life. Local facilities are regularly used and all residents are encouraged to have a holiday away from the home annually. The home encourages all residents to become involved in menu planning with individual choice. EVIDENCE: Information from resident’s files and staff spoken with shows the home has developed links with local churches and residents visit local amenities for shopping trips, meals out and walks. All residents attend the Gateway club one evening a week. Staff and two residents stated they are looking forward to holidaying in Spain in the summer period. One resident said they enjoyed the food at Fairfax Road. Comments included “ I say what I want ” and “food nice”. Staff and residents participated in verbal banter and the social atmosphere was good throughout the day. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 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 standard(s) 19, The care documentation has improved since the last inspection, although residents’ involvement is limited because of their learning disability. Medication is well managed and external professionals meet identified health needs. EVIDENCE: All four residents care plans were inspected. All contained a photo of the resident, personal details of family and friends, medical details and preliminary assessment of living skills. The manager is the main person that completes the care plans and risk assessments. However staff members have a good knowledge of the persons living at the home and described different ways in which residents are assisted and their needs met. There were good communication systems in place to ensure the changing needs of residents were met. This was seen in the care plans. Health care visits are recorded in residents files. Medication is well managed within the home reducing the risk of errors and the home works effectively with healthcare services. The relatives of two resident responded on comment card how happy they are with the care at Fairfax Road. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 12 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 The home provides clear information on how to make a complaint about the service. It includes reference to the Commission for Social Care Inspection if people wish to take a complaint outside the home. EVIDENCE: The complaint procedure is displayed in the main hallway. The manager demonstrated a good understanding of the requirements of protection of Vulnerable Adults. One member of staff spoken with was clear about reporting and recording any suspicion of abuse. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 13 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) 25,26,27,28,29,30 The home provides a safe environment for residents and staff. Physical standards within the home appear to be adequate and comfortable for residents. It is evident that the individuality of each resident is promoted. EVIDENCE: Residents’ bedrooms meet their own needs, with all having single accommodation which meets minimum space. Their rooms have recently been decorated are comfortably furnished and meet individual resident needs. The home provides appropriate communal space of a high standard for residents for dining as well as recreational purposes. Residents are able to meet with visitors in private in their own rooms, or communal areas if they wish. Moving and handling aids, including hoists, are available to meet the assessed needs of residents. The home is clean and free from offensive odour throughout, with systems in place for infection control. The policies for infection control are regularly updated. The home appeared safe from hazards that may put residents at risk. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 14 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) 36 At the moment a system for formal staff supervision is not in place in the home. This system would enable staff to receive direct feedback about their work and discuss any concerns they may\may not have. EVIDENCE: Discussion with staff led to the conclusion that staff have a good knowledge of individual resident and seemed to understand the importance of encouraging residents to maintain their independence and dignity. Although working relationships with the manager and staff appear to be good, formal supervision would enhance this, giving staff the chance to discuss work, training, colleagues, residents and the ways in which standards of care could be improved for residents. Such one to one session’s between staff members and the manager should improve working practices.. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 15 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) 37,38,43 The manager is highly respected, hardworking and committed to providing a quality service for the residents. EVIDENCE: The manager and senior staff are familiar with conditions associated with the residents and were able to demonstrate this knowledge through discussions with them. Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 16 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 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score 3 4 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 2 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 4 3 4 3 3 x x Standard No 11 12 13 14 15 16 17 x 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x x x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Fairfax Road Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x x x x x x J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 17 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 6 Regulation 15 Requirement The registered manager must ensure residents care plans contain sufficient information relating to specific care needs and risk. The manager must ensure all members of staff have regular formal one-to-one supervision sessions. Timescale for action 20/6/05 2. 36 18 20/6/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 18 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 Fairfax Road J52 S1449 Fairfax Road V222412 260405 Stage 4.doc Version 1.30 Page 19 - 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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