Inspection on 17/01/06 for Gledhow Wood Road

This inspection was carried out on 17th January 2006.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Gledhow Wood Road 22/01/09

Gledhow Wood Road 02/02/07

Gledhow Wood Road 03/10/05

Gledhow Wood Road 08/02/05

Gledhow Wood Road 29/06/04

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

CARE HOME ADULTS 18-65 Gledhow Wood Road 68 Gledhow Wood Road Leeds West Yorkshire LS8 4DH Lead Inspector Kathleen Firth Unannounced Inspection 17th January 2006 12:40p Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 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 Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 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. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Gledhow Wood Road Address 68 Gledhow Wood Road Leeds West Yorkshire LS8 4DH 0113 217 9500 0113 217 9500 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) TACT Mr Patrick Cassidy Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd October 2005 Brief Description of the Service: The home is located in a residential area of Oakwood, north of Leeds. It is a detached building and does not look any different to the other houses within the road. The residents bedrooms are on the ground and first floor, with office space and the staff bedroom on the top floor. There are large attractive gardens to the rear of the building. Personal care is provided for five residents who all have a learning disability. The local healthcare team offer good support to the residents. The home is within walking distance of a supermarket, shops, bank and a post office and the residents are able to make use of these facilities. There is a car at the home to make sure the residents are able to attend any appointments they have and to take them on trips out. A regular bus service to the city centre is available. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 2.75 hours on Tuesday 17th January 2006 by one inspector. The inspector looked around the building, examined records including care plans, staff files, medication records and the Service User Guide. The manager, staff and residents were all helpful throughout the inspection. Three staff members and two residents were spoken to. What the service does well: The home promotes independence and positive relationships between staff and the residents. Residents are treated with respect and given as much responsibility over their lifestyle as they are able to accept. They live in a safe, comfortable environment cared for by staff that have a good understanding of their needs. A nucleus of the staff team has worked together over many years and the residents have benefited from this continuity of care. A good range of activities is offered to the residents and some attend day care or do paid work. Residents are taken out in groups or on a one to one basis depending on their needs. They have some choice over which member of staff takes them out. Eating out is something that some residents enjoy but others prefer to have a takeaway at home. Some people choose to go to the local pub and the community has accepted them here. Family and friends can visit and residents either stay at home with them or go out and about. Residents are able to spend time away from the home with their parents if this has been agreed in their care plan. The residents are encouraged to take some responsibility within the home and are expected to take part in cleaning of their rooms and doing their laundry. They also help in the kitchen and dining room, laying the table for meals and washing up afterwards. It was evident at the inspection that residents are able to talk with the manager and staff and that they are listened to. There is a car at the home and a driver is always on duty to make sure that residents are able to go out and can attend any appointments they may have. Training is seen as important at the home and staff confirmed that they are offered appropriate opportunities. All of the staff have achieved or are working on an NVQ (National Vocational Qualification). The home operates a robust recruitment policy to safeguard the residents and all new staff are given mandatory training. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 6 What has improved since the last inspection? 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. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 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 Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 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): 1, 2, 3 Residents and their carers can be sure that the home will meet their needs and aspirations. All of the present residents were assessed prior to their admission to the home. EVIDENCE: The manager assessed all of the present residents before they moved into the home to find out their needs and aspirations. They were given information about the home and were able to visit and spend time here. The manager and his team have worked very hard to make sure people’s aspirations were reached as far as possible. They are all encouraged and enabled to do what ever they choose to fulfil their lives. Some of the staff team and the manager have worked with these residents for many years and have a good understanding of their needs. The Service User Guide gives prospective residents sufficient information about the home and what services they can expect. Residents have their own copy of this. There have been no admissions since 1997 when the present residents moved from hospital although one person moved in a couple of months after the others. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 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): 6, 7, 10 Comprehensive care plans are in place for all residents with risk assessments where required. Residents are involved in the day-to-day decision making about their lifestyle. Confidential information about the residents is stored correctly. EVIDENCE: All of the residents have comprehensive care plans that give information about their needs. These are very specific with detailed instructions where appropriate. An example of this is too check one particular resident’s mood before taking him into a shop as failure to do so could lead to difficulties. The residents are involved in drawing up these plans and evidence was seen of this. The plans are reviewed on a regular basis but a paper record of this procedure needs to be in the file. The residents are included in most aspects of decision making about their lives including what time they want to get up and who is to help them. They are able to speak with the manager and staff at all times and they have meetings, which they are encouraged to attend. They choose where they want to go out to and who is to take them. Where to go on holiday and who is going with them is another example of the choices they make. Some people go away Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 10 with one staff member and others may go in a small group. Through the years the staff have worked out the best way for the residents to get as much out of holidays as possible and make the appropriate arrangements. Some of the residents need a good deal of personal support whilst others only require prompting. The manager and staff feel that the residents enjoy taking some responsibility for their lifestyle and have responded in a positive way. The residents are aware that information is kept about them and that they can look at this if they choose. All information was seen to be stored correctly and confidentiality is very high on the agenda at the home. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 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 the following standard(s): 11, 12,13,15,14,16,17 Appropriate activities are arranged for the residents. The rights of the residents are respected at all times. EVIDENCE: Residents are supported to take part in valued activities that suit their interests and lifestyle. They enjoy going out for meals or having a takeaway, shopping, listening to music and going to the pub. The ones who go to the pub are seen as part of the community when they do this. One person enjoys bus and train rides and goes into town each weekend on his own. Three of the residents attend day centres and one works at a jeweller’s shop and is interested in learning more about jewellery. One person is taken out by “Opportunities” that is a part of the organisation that operates the home. The manager is trying to have this time increased as he feels this is required. Family and friends visit when they choose and some keep more close contact than others. The home welcomes visitors and staff are always ready to speak with them if they have any concerns or worries. The residents are encouraged to be independent wherever possible and are involved in household activities. They all take some responsibility for cleaning Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 12 their rooms and laundry. The residents are involved in setting the table for meals then clearing away and washing up afterwards. They take responsibility for making their own supper although one resident often makes drinks for some of the others. The residents are involved in doing the shopping and some are able to go to the shops independently and collect small items. The main meal of the day is served in the evening and staff and residents eat this together. They do not use menus as the likes and dislikes of the residents are well known to the staff. Alternatives are offered if someone does not like what is being offered. Excellent records of what individuals have eaten are kept and weight records are kept as required. One resident has recently seen his GP as staff observed that he has been losing weight. The records show that the home offers a good, varied and nutritious diet. Staff shop locally and use fresh food to prepare meals. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 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 the following standard(s): 20, 21 The home has a policy and procedure in place to deal with residents’ medication. Staff are aware of the residents’ needs, they are treated with dignity and their privacy maintained at all times. EVIDENCE: None of the present residents are able to manage their own medication and the home has a policy and procedure in place to deal with this. One staff member is responsible for the ordering and returning of medication. All records and storage of medication were seen to be correct. The home uses the Boots MDS system and most staff have been trained to administer this. One staff member is due to attend training next week. The manager has discussed the residents’ wishes with them about what they want to happen following their death. These discussions are recorded along with any wishes that the resident has made known. One person has no family and an advocate has been requested to help him. Where there are families everyone has been involved in the discussions. If a resident becomes ill the manager said that if at all possible he would be allowed to stay at the home if they could continue to meet his needs. Family, GP and any specialist carer would all be involved before a decision was made. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 14 Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Residents and their relatives have their views listened to, taken seriously and action is taken to resolve them. Residents are protected from abuse. EVIDENCE: The home has a Complaints policy and all residents are given a copy of this when they are admitted to the home. Most of the present residents are able to voice any concerns or worries and the staff are able to recognise if others are upset by observing their behaviour. Staff at the home are able to speak to staff at the day centres and will be told about any problems that may arise there. The home has a comments book where people can write things if they feel unable to voice them but this is rarely used. Good interactions were seen between staff and residents throughout the inspection and it was obvious that they are used to coming into the office. All staff have now attended some Adult Protection training and the manager is confident that they will recognise the signs and symptoms of abuse and know what to do. In the past there have been incidents of residents being angry and behaving inappropriately. However these incidents have decreased and residents handle their anger much better and only rarely does anyone display unacceptable behaviour. Financial records are well maintained and money seen to be kept in the safe. Most of the residents’ money is handled by the company’s head office with only personal allowances being dealt with at the home. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 16 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): 25, 26, 27, 29, 30 The home offers a safe environment for the residents and provides them with suitable accommodation. EVIDENCE: The home offers a safe, welcoming and comfortable environment, with the décor and furniture being of a good standard. It is clean and hygienic throughout and is maintained to a good standard. A new kitchen and shower are planned in the near future. No smoking is allowed in the lounge/dining room or bedrooms. There are sufficient toilets and bathrooms to meet the residents’ needs and one bathroom has been repaired since the last inspection. Soap and towels were seen in some of the bathrooms but not all. Residents have sinks in their own rooms and tend to use these to wash. The home is suitable for the present residents but the manager said that the time may come when specialist equipment may be needed e.g. a stair lift. He and his team know how to obtain any specialist equipment that residents may require to retain their independence. Residents have personalised their own rooms by having their possessions around them. The amount of things they have depends on them and some Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 17 choose not to have too many things around. One particular resident does not like having anything new in his room and gentle persuasion is needed to help him accept anything that is needed. Keys are offered to the residents and most of them choose to lock their rooms. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 18 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): 31, 32, 33, 34, 35, 36 Staffing numbers and skill mix make sure that the residents’ needs can be met. Residents are protected by the home’s recruitment policy. EVIDENCE: All of the staff are working on or have completed NVQ at varying levels and staff stated that they have good access to training. However if there are staff shortages on a particular day staff may be unable to attend planned training. The staff team work well together and communication between them is very good. Part of the team have worked together many years with others coming and going during this time. Some people who have left have done so to gain qualifications or to get a better job. The residents have benefited from continuity of care. All the staff know and understand their own role and responsibilities and those of their colleagues. There were sufficient staff on duty during the inspection and everyone said that this was normal practice. There is always a driver on duty and sufficient staff to allow residents to be taken out or have one to one time spent with them. The home operates a key worker system but this is not exclusive and all staff members are included in the care of all residents. The home has two vacancies at present and interviews for these are to be held next month. Only two agency staff are used to cover the vacancies and again Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 19 this provides good continuity for the residents. The home’s operator’s carry out recruitment centrally but the manager will be involved in the process. Staff files contain all the required documentation and the latest person appointed was subject to CRB, POVA, Visa and work permit checks plus had to provide two written references. These were all seen in his file. Supervision sessions are in place with written records and regular staff meetings are held. An agenda that everyone can contribute to plus the minutes of the meetings are made available. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 20 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, 38, 42, 43 The home is well managed; the health and safety of the residents and staff are seen as important and safeguarded at all times. EVIDENCE: The manager has many years experience working in this field and offers excellent leadership to the staff. He has completed half of the work towards his Registered Manager’s award but there has been a problem with this being assessed as his appointed assessor left the post. This has gone on for a few months and the manager is trying to rectify it. Staff spoken to confirmed that he is a good manager, offering good support and always ready to speak with them and listen to ideas put forward. One person described him as the “best boss” she has had. Good interaction was observed between him, his staff and the residents. Residents approached him throughout the inspection and he showed patience and understanding when dealing with them. Overall responsibility for health and safety within the home lies with the manager but some tasks are delegated to other staff members. Fire bells are tested weekly and fridge/freezer temperatures taken daily. One staff member Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 21 has recently completed the training for PAT testing and is now responsible for this at this home plus one other. Another is responsible for fire safety within the home including training. A movement and handling coordinator is to be confirmed shortly. The manager voiced some concerns about these arrangements, as he is worried it may have an impact on residents care at the home if his staff have to go elsewhere to perform these duties. The housing association that owns the home is responsible for annual checks on the boiler, electrical wiring and other safety checks. Two members of staff are named as the designated first aid people within the home although all staff have training in basic first aid. Nothing was seen during the inspection that could cause a hazard to residents, visitors or staff. The TACT head office is responsible for maintaining the accountants for the home and these were not available at the time of the inspection. Records seen concerning the residents’ allowances were correct and the monies kept locked in individual tins within a safe. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 22 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 X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score X 3 3 3 X N/A 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Gledhow Wood Road Score X X 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 X X X 3 3 DS0000001455.V273631.R01.S.doc Version 5.0 Page 23 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. Standard Regulation Requirement Timescale for action 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 YA 6 Good Practice Recommendations A written record of care plan reviews needs to be available in the residents’ files. Gledhow Wood Road DS0000001455.V273631.R01.S.doc Version 5.0 Page 24 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. 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