CARE HOME ADULTS 18-65
House Of Light 13 Allerton Park Leeds West Yorkshire LS7 4ND Lead Inspector
Linda Trenouth Unannounced Inspection 10th January 2006 02:00 House Of Light DS0000001469.V276528.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 House Of Light DS0000001469.V276528.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. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION
Name of service House Of Light Address 13 Allerton Park Leeds West Yorkshire LS7 4ND 0113 268 1480 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) Catholic Care (Diocese of Leeds) Miss Aileen Donnelly Care Home 6 Category(ies) of Learning disability (6) registration, with number of places House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 19th July 2005 Brief Description of the Service: The House Of Light provides accommodation for 6 male and female service users with learning disabilities aged over 35, but does not provide nursing care. The home is based in a large detached private house situated in the residential area of Allerton Park. The accommodation is on four floors with 6 single bedrooms based on the lower ground, 1st and 2nd floors. There are three reception rooms based on the ground floor providing alternative communal seating and activity areas. The House of Light home has extensive gardens and is near to the local shops and community facilities in the Chapel Allerton area. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The Commission for Social Care Inspection has to carry out at least two inspections of care homes every year. The inspection year runs from April to March and this was the second inspection visit for 2005/2006. Copies of previous inspection reports are available at the home or on the Internet at www.csci.org.uk. The last inspection of the home was on the 26th July 2005. There have been no additional visits made to the home since the last inspection. This was an unannounced inspection carried out by one inspector who was at the home from 14.00 until 18.00. The main purpose of this inspection was to make sure that the home continues to provide a good standard of care for the residents. The methods used at this inspection included looking at care records; observing working practices and talking to residents and staff. Comment cards were left at the home to provide residents and visitors with the opportunity to comment on the service. Feedback was given to the senior carer at the end of the visit. Requirements and recommendations made during this visit, and outstanding from previous inspection visits can be found at the end of the report. What the service does well:
The home has a friendly and welcoming atmosphere. Care is provided in a clean, tidy and well maintained building. The manager and the staff continue to provide good opportunity for residents personal development. Daily living skills are assessed and a programme of individual development is introduced. Individual residents are also supported in their communication skills both verbal and non-verbal. The staff promote and encourage all the residents to be independent as possible and to reach their full potential. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 6 Residents said that staff are kind and treated them with respect, they felt valued and their feelings and opinions mattered to the staff at the home. Residents said they felt safe in the home. Residents continue to enjoy an extensive and diverse range of day care, leisure activities and holidays. They have good opportunities for integration into community life. The residents are supported in every aspect to develop and maintain personal and family relationships. The management and staff make sure that residents make meaningful decisions about their lives and participate in the daily day-to-day running of the home. What has improved since the last inspection? What they could do better:
The manager must make sure that all documentation for the international staff be interpreted into English to ensure safe recruitment, this is necessary for all references and police checks. In one bedroom the lighting level was of concern. It was recommended that with the agreement of the resident this be increased. The manger is registered with the CSCI and has not yet completed the Registered Managers Award NVQ level4. This training must be completed to make sure she is sufficiently trained to meet all the management and care needs of the home. The manager has registered to undertake this award with House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 7 Thomas Danby College but has not yet commenced the award. The commence date is April 2006. 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. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 8 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 House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 9 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): Not reviewed. EVIDENCE: House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 10 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): Not reviewed. EVIDENCE: House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 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. The residents have opportunities for personal development in a meaningful way. EVIDENCE: House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 12 The manager and staff make sure that residents decision making is central to their care planning and all have good, person centred plans. The residents choose from day-to-day activities and also long-term events planning. Residents spoken to confirmed that they have many opportunities and choices both in and beyond the home. They are involved in many vocational activities beyond the home. These include evening classes at the local college in areas such as cookery, art and crafts, sports and exercise. One resident has a paid job in catering at a local centre. The staff of encouraged him in this work and he enjoys his weekly wage and is gaining in confidence. He is also learning sign language because the centre where he works is for clients who have communication difficulties. The staff also make sure that residents enjoy regular daily activities and they choose from walks, going to local pubs for lunch and picnics or day trips. Residents also choose from holidays throughout the year including summer holidays to Spain and walking holidays in England with weekends away to places like Blackpool. Special events are planned with the residents including a recent Halloween party and later a Christmas party where the residents decorate the home and help prepare the food. From the comment cards received and from discussion with residents it was clear that residents were happy with the activities provided by the home. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 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 and 21 The ageing and illness of residents is handled with respect and in the best interests of the individual. Service users are supported with their own medication and safe systems are in place for the administration of medication. EVIDENCE: From discussion with residents and review of documentation it was clear that where residents physical ability was deteriorating this was reviewed in their care plans and support mechanisms were put into place. There are examples of this given in personal care where residents were supported to be as independent as possible in areas such as shaving and dressing. The staff reviewed the individual care plans and the way in that they could best meet the needs of the resident both now and in the future. Where health needs are deteriorating this has meant some changes to daily routines of the individual but it is commendable that the staff continue to be innovative and strive to ensure that the residents independence and dignity is always maintained. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 14 A good example of this had been to encourage one resident to feel more included by encouraging him to use his camcorder camera on holiday and when visiting places or recording events in the home. They also meant an increase in more one to one activity with staff helping him visited places that inspire his interests in filming and photography. The medication storage and medication records were all reviewed and were found to be well organised and maintained. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 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): Not reviewed. EVIDENCE: House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 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): 24 and 25 The home is comfortable and provides adequate communal space whilst ensuring adequate privacy is protected in other areas of the home. Generally the lighting and heating was satisfactory in the home, however this must be kept under review to ensure that changing needs are met. EVIDENCE: The communal areas of the home complement and supplement the residents own bedroom space. The home throughout is homely and comfortable one resident was keen to show me his new carpet, which had been recently fitted in his bedroom. The resident informed me that he had everything he needed in his room and had arranged it just the way he liked. Bathrooms and toilets are comfortable and well maintained. They are decorated and furnished in a pleasing homely style. Discussion was held with staff regarding a residents bedroom where the light levels were low. It was felt that this might be a health and safety hazard for
House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 17 this resident who had limited sight. The table lamp in the room also required replacing. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 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): 32, 33, 34 and 36. Generally the home ensures the safe recruitment of staff to the home but documents that are not translated into English undermine this. EVIDENCE: New recruits to the home were reviewed and generally safe recruitment had been undertaken. Application forms were available, references and CRB or international police checks had been undertaken. The home annually employs international staff and some of the information provided was in the original language. The manager must ensure that all references and checks are translated into English to make sure that recruitment is safe. The new staff showed me their induction recorded and were able to account for their training at the home. They had undertaken training in the basic principles of care, health and safety, adult protection, first aid and food hygiene. There are three members of staff who have achieved NVQ level2 or equivalent and a further two members of staff who are presently on the award, on the completion of their training the home will meet the standard. Staff have also undertaken further training in medication, first aid, adult protection, challenging behaviour and sexual health for people with learning disabilities. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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, 41 and 42. The home is well managed and the health and safety is seen has very important to the manager and staff of the home. The manager has many years experience of the client group and has good leadership skills but must complete training to fully meet the standard. The management and staff at the home create an environment of openness and respect. The residents are safeguarded by comprehensive and well-managed policies and procedures. EVIDENCE: The manager and the staff work together to make sure that the home is well run and the needs of the residents are met. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 20 Residents spoken to and observed confirmed that they are included in daily decision-making and their views and opinions are sought. Regular house meetings are held and documented. The policies and procedures at the home are robust and the manager and deputy manager regularly audits them to ensure they are current and up to date. Copies are available for staff and residents to read. The manger has not yet completed the Registered Managers Award NVQ level4. This training must be completed to make sure she is sufficiently trained to meet all the management and care needs of the home. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 21 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 x ENVIRONMENT Standard No Score 24 2 25 3 26 x 27 x 28 x 29 x 30 x STAFFING Standard No Score 31 x 32 3 33 3 34 2 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 4 12 x 13 x 14 x 15 x 16 x 17 x PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score x x 3 3 2 3 x x 3 3 x House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 22 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 YA24 Regulation 23 Requirement The lighting levels and table light in the bedroom discussed must be reviewed to ensure the continued safety of the resident. The manager must complete level 4 NVQ in management by 2005. (carried forward from 31.12.05) Staff recruitment documentation must be translated into English. Timescale for action 20/03/06 2. YA37 9 20/03/06 3 YA34 19 20/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard 32 Good Practice Recommendations The home should ensure that a minimum of 50 of the staff are qualified to NVQ level 2 or above. House Of Light DS0000001469.V276528.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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