Inspection on 31/08/05 for Ferncliffe Road

This inspection was carried out on 31st August 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

Ferncliffe Road 23/01/07

Ferncliffe Road 27/01/06

Ferncliffe Road 11/01/05

Ferncliffe Road 27/08/04

Ferncliffe Road 31/03/03

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood Hall

Muston Road (70)

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

CARE HOME ADULTS 18-65 Ferncliffe Road 19 Ferncliffe Road Leeds West Yorkshire LS13 3PH Lead Inspector Carol Haj-Najafi Announced 31 August 2005 st 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. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Ferncliffe Road Address 19 Ferncliffe Road Leeds LS13 3PH 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 2557443 0113 2361537 Community Integrated Care Mr Jason Dear Care Home Only 4 Category(ies) of Learning disability (4) registration, with number of places Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 11th January 2005 Brief Description of the Service: Ferncliffe is a single-storey purpose built home situated in Bramley. It has a large enclosed garden to the rear of the building. A car parking area is located at the front of the building. Local shops and Bramley town centre are within easy access.Ferncliffe Road is part of the Community Integrated Care organisation, and is registered to provide personal care for up to 4 people with learning disabilities. The accommodation consists of four single bedrooms, a lounge and separate dining room, shower room and bathroom, laundry, and a domestic style kitchen. All laundering is undertaken on the premises.The home has a vehicle, which is utilised by service users on a regular basis. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 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 1.30pm. 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 two staff and the registered manager. Service users living at the home have complex needs, and discussions with service users are very limited. Records were inspected including service user plans, risk assessments, daily records and staff training records. A pre-inspection questionnaire was sent into the Commission before the inspection. What the service does well: What has improved since the last inspection? Staff and the manager are more aware of the local adult protection procedures. The manager has attended Protection of Vulnerable Adults training. Most staff have worked at the home for quite a long time. This has provided an opportunity to develop good teamwork and communication. One staff and the manager said there had been an improvement in these areas. The bathroom has had ceiling tracking installed, which is better for service users when they are being hoisted. New carpets have been laid in the hallway, corridor and dining room. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 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 Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 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) 1 CIC have failed to provide a record of the care home’s charges and amounts paid by or in respect of service users. This is a breach of regulations and prevents service users or their representatives from having access to information which they are entitled to see. EVIDENCE: No service users have moved into the home since March 2003, therefore standard relating to choice of home were not looked at. However, the standard relating to care home charges was looked at to establish whether the requirement for the last inspection had been met. Service users and the manager do not know how much the organisation charges for each placement. This information has been requested since June 2003. The manager has regularly tried to obtain this information from CIC but has been unsuccessful. The regulations clearly state this information must be available in the home. Service users or their representative and the manager have a right to access this information. A scale of charges from benefits claimed on behalf of service users has been made available to the home but this does not provide full details of the amount charged by CIC in respect of each service user. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 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, 9 Information recorded in care plans and risk assessments is good. New plans that are being introduced will further enhance the care planning process. Some information was not up to date, and although time has been spent setting up the new plans, it is important to make sure current service user needs are recorded. EVIDENCE: Staff had very good knowledge of the people living at the home and were able to describe the care and support given to individual service users. Two service user’s records were looked at. Each service user has a care plan, risk assessments and a review file. Care plans were very individual and written using a person centred approach. Risk assessments are completed and action points are well defined. Service users have keyworkers and they are responsible for making sure care plans, risk assessments and reviews are up to date. All plans are being transferred to a new style plan, which will provide clearer and more accessible information. The new plans were being introduced at the Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 10 last inspection but all are not yet complete. This has resulted in existing plans being out of date and the new plans not finished, therefore some key information about changes in service user’s needs was not written down. The manager has set a target date of the end of September to have all plans finished. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 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 Service users receive an individually tailored care service, which consists of varied and regular activities. The home is very good at encouraging and supporting service users to maintain a strong relationship with their families. EVIDENCE: When staff and the manager spoke about service user’s lifestyle, they talked about the importance of family involvement. The home transports family members to the home once a week, this enables service users to have regular contact. Daily records confirmed that staff support service users and their relatives to go out into the community. Staff talked about the recreation that service users enjoy; outings are very popular. Various in house activities are provided. Daily records confirmed that regular outings and activities are arranged. On occasions outings cannot be arranged because there is no driver on duty or not enough staff. Different day care arrangements are in place, some service users attend external day care services, others receive activities through the home. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 &19 Individuality is clearly promoted in the home and service users receive personal support in the way they prefer. The systems in place for ensuring health care needs are met are good. EVIDENCE: Staff spoke about flexibility, privacy and the individuality of each service user. Care plans and risk assessments provide guidance on how personal care should be provided and techniques for moving and handling. 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. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 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 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. Good financial systems are in place. EVIDENCE: Service users are generally not able to say if they are satisfied with the service. Two staff and the manager spoke about observing service users, and using knowledge and experience to identify when service users are unhappy. Service user plans have information which indicate when someone is unhappy. No complaints have been received during the past twelve months. The home has a complaints procedure, which is displayed in the entrance. The home has adult protection policies and procedures. The manager had a clear understanding of the procedures and responsibilities for reporting allegations. Staff were also aware of the procedures, and how to safe guard adults from abuse. The manager has attended Protection of Vulnerable Adults training and is waiting to attend adult protection training with the local authority. Service users financial records were looked at. All expenditure is clearly recorded and receipts are obtained for purchases. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 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 standard(s) 24, 25, 26, 27, 28, 29 & 30 Ferncliffe Road is homely, and nicely decorated and furnished. It is clean and well organised. Service users have lovely personalised rooms. Specialist equipment has been obtained to meet individual needs. 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. A ceiling track hoist has been installed in the bathroom, and a new changing bed has been purchased. This is now a better and more comfortable environment for service users that need hoisting. Two new hoists have been purchased, one of which is a folding hoist. Different equipment was available to help maintain independence. The furnishings, carpets, and furniture are good quality and the home is decorated to a reasonable standard. The lounge suite and carpets in the hallway and dining room have been replaced. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 15 Staff said the environment was always clean and tidy. A washing machine, with a sluicing facility and an industrial dryer are provided. Procedures are in place for control of infection. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 16 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) 32, 33, 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. The home must review the staffing levels to ensure all service users receive the proper care they need. EVIDENCE: The inspector spoke individually to three staff including management. Everyone said they thought the home provided a good standard of individualised care. They also thought the team worked well together, and felt there had been improvements in communication. A low turnover of staff has provided consistency and continuity. Staff had a good understanding of service user’s needs and keyworker responsibilities. The home has a minimum of two members of staff on duty for each day shift and one waking night staff, often three staff are on duty during the day. There have been some changes in service user’s needs over recent months, and two service users require additional support. One service user always requires two staff to meet their personal care needs. The manager and staff confirmed that the service user often requires assistance during the night but it has not been possible to provide support because the required number of staff are not available. The daily records confirmed that the service user is often Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 17 awake during the night. This must be reviewed. Staff also said it is sometimes difficult to arrange community activities because of staffing levels or insufficient drivers. Staff have attended training courses which cover health and safety areas and good care practice; these include, fire safety, first aid, food hygiene, medication administration, and risk assessment; four staff are completing NVQ level 2 and two are due to start. The manager said one staff has completed a qualification that is equivalent to NVQ level 2. The home is working towards the 50 target of trained staff by the end of 2005. Individual training records and the team training plan was looked at. Staff receive monthly supervision, and attend monthly staff meetings. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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) 38, 40, 41 & 42 The home’s manager has a good understanding of the needs of service users and provides strong leadership. Recording systems are good. The health and safety of service users and staff are protected. EVIDENCE: The manager spoke of service user’s needs and was aware of what was happening in the home. Systems are in place to ensure staff and service users receive support and guidance. Strategic plans are in place to ensure the home continues to develop and operates smoothly. 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. A copy of the electrical wiring certificate was seen. Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 19 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 2 x x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 4 3 3 3 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 4 x x Standard No 31 32 33 34 35 36 Score x 2 2 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Ferncliffe Road Score 3 3 x x Standard No 37 38 39 40 41 42 43 Score x 3 x 3 3 3 x J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 20 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 YA1 Regulation 17(2) Requirement The registered provider must ensure a record of the current range of fees is kept in the home. (Timescales of 31st March 2005, 30th November 2004, 29th February 2004 and August 2003 not met) The registered manager must ensure service user plans are up to date. The registered provider must review staffing levels to ensure serice users assessed needs are met. Support during the night must be considered a priority. Timescale for action 30th November 2005 2. 3. YA6 YA33 15 18 31st October 2005 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. No. 1. Refer to Standard Good Practice Recommendations Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 21 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 Ferncliffe Road J52 J03 S1450 Ferncliffe Road V214143 310805 Stage 4.doc Version 1.40 Page 22 - 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. 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