Inspection on 11/10/06 for Ivy Cottage

This inspection was carried out on 11th October 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

Ivy Cottage 03/02/09

Ivy Cottage 23/01/06

Ivy Cottage 09/08/05

Ivy Cottage 08/11/04

Ivy Cottage 12/07/04

Ivy Cottage 02/03/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Ivy Cottage Ackton Lane Ackton Featherstone West Yorks WF7 6HP Lead Inspector Elizabeth Hendry Key Unannounced Inspection 11th October 2006 08:30 Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 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 Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 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. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Ivy Cottage Address Ackton Lane Ackton Featherstone West Yorks WF7 6HP 01977 701370 01977 795707 ivycottage1@tiscali.co.uk 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) Ivy Cottage (Ackton) Limited Ms Tracy Michelle Wetherald Care Home 10 Category(ies) of Learning disability (10) registration, with number of places Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2006 Brief Description of the Service: Ivy Cottage is a care home providing personal care and accommodation for 10 younger adults who have a learning disability. Many of the service users present with complex needs including the management of challenging behaviour. The home is situated in Ackton, a small residential suburb of Featherstone, and is some distance from local amenities. It is privately owned and has two sister homes which also accommodate this category of service user. The premises, that are not purpose built, have service user accommodation arranged on two floors. All bedrooms are designed for single occupation and there is adequate communal space. The home has a small open garden to the front of the house and a pleasant secure courtyard to the rear along with car parking facilities. Weekly fees within the home at the time of the inspection ranged from £2,000 to £2,600 dependent on the assessed needs of individuals. The manager confirmed that existing and prospective service users are provided with a Service User Guide detailing what services are provided and the aims and objectives of the organisation. Additional copies are available upon request. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the home’s annual inspection which took place on an unannounced basis between 08.30hrs and 13.30 hrs. One inspector, Elizabeth Hendry, undertook this visit. As part of the key inspection, CSCI have had contact with the following people: residents, the service provider, staff members, social workers and GP. During the site visit records, observations and discussions with both residents and staff were undertaken. We sent out 10 resident questionnaires, 10 relative, 5 social worker questionnaires and one GP questionnaire. At the time of writing this report, 9 resident, 4 relative, 5 social worker and one GP questionnaire had been returned. In writing this report, information and evidence was not only obtained by way of visiting the home but information and evidence was obtained from notifications sent to the CSCI since the last key inspection in February 2006, questionnaires, and the last inspection report. The inspector would like to thank residents and staff for their hospitality and cooperation throughout the inspection. What the service does well: The home continues to be run in the best interests of residents and is a service committed to delivering high quality care and support. Residents spoke of enjoying living at the home, and spoke highly of all members of staff involved in their care. The home works hard ensuring all residents have access to a wide range of community based activities, educational and voluntary work opportunities, with staff being made available where this has been assessed as being needed. The inspector acknowledges the continuing positive attitude of support workers towards residents and the positive relationships that appeared to have been fostered. The home provides a relaxed and informal atmosphere which promotes the notion of the home being an extended family. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 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. The summary of this inspection report can be made available in other formats on request. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 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 Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents move into the home following an assessment of their health, personal and social care needs. EVIDENCE: A sample of resident care plans were viewed, of those seen all contained a pre admission assessment that clearly identified individual needs in areas such as personal, physical, emotional, social and educational care. The service manager confirmed that prospective residents undergo a detailed assessment prior to a placement being offered within the home to ensure that all of their needs can be fully met. The manager confirmed that no residents would be accepted into the home unless this could be determined. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed information of residents’ health, personal and social care needs are set out in an individual plan of care. Detailed risk assessments are in place enabling residents to be protected and take measured risks. Residents are always cared for in a manner that maintains their dignity and affords respect. EVIDENCE: Staff spoken to were knowledgeable as to the individual needs and personal limitations of the residents in their care. All of the care plans viewed contained sufficient information which clearly detailed the needs of each resident and the manner in which staff should provide support and assistance. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 10 Observations made of staff interacting and working with residents clearly evidenced their awareness of the contents of the care plans. The manager explained that all residents are encouraged and supported in writing their care plan. Copies of care management assessment were held within all of the individual plans seen on the day of the inspection. Residents’ records and, in particular, risk assessments show that steps are taken to minimise any risks to residents who are encouraged to live as ordinary a life as is possible. Questionnaires asked residents whether they were able to make their own decisions. Of those returned to CSCI, 3 indicated that residents are always able to make decisions about what they do each day, and 6 indicated that they are sometimes. Of the residents spoken with, all confirmed that they are involved in the day to day running of the home. Regular resident meetings take place, both in a group setting and on a one to one basis. Each resident has a personal bank account and, dependent on personal preference, the bankbook and monies are either kept in individual bedrooms or locked in the office cabinets. Access is gained through request to staff member and is available at all times of the day. The manager told the inspector that budgeting skills are taught, and identified as an individual goal. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with opportunities for personal development and to take part in age, peer and culturally appropriate activities. Residents play an active part within their local community and are supported to take full advantage of ordinary community based leisure activities. Positive relationships with relatives are openly encouraged. Residents are offered a healthy diet and enjoy their meals and mealtimes. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 12 EVIDENCE: All of the residents at Ivy Cottage have a varied and fulfilling activity programme. During the inspection, all residents were involved in activities of their choice. The activity coordinator was spoken to at length to determine the extent of the activities available within and outside the home. The activity co-ordinator confirmed that each resident has an activity care plan within their files which identifies their personal likes, dislikes and aspirations. One resident spoken with said that they prefer to stay at the home and take part in cookery, exercise videos or arts and crafts. Another resident said that they enjoy going across to the local village green to ride their tricycle. The activity co coordinator spoke of a resident recently gaining employment within the local community and confirmed that they would be receiving full staff support to do this. Staff rotas examined prior to the visit to the home indicated that sufficient staff are always on duty to ensure residents are able to access these activities with support if needed. Additional activities include swimming, cinema, gardening, visits to local nightclubs, shopping, arts and crafts and computers. The inspector observed residents enjoying their lunch, each resident had clearly chosen what hey would like and there was a lot of different meals being eaten. Menus submitted to CSCI prior to the visit confirmed that a varied, balanced and nutritious diet is available Meal times are flexible, relaxed and unhurried, with residents being able to choose where and when they wish to eat. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive personal care in a manner that they prefer. Records viewed identified that residents’ health care needs are met. Residents are protected by the home’s medication policies and procedures. EVIDENCE: The inspector viewed care plans that clearly identify individual needs, and personal care requirements. The home has a relaxed and flexible environment allowing residents to maintain control over their own lives. The home operates a key worker system. The inspector was told by the manager that all residents are given the choice of GP and are assisted to access more specialist assistance when required. The home monitors the residents’ health needs closely and problems identified are quickly addressed. Regular appointments with dentists and opticians are Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 14 maintained. Medication is reviewed frequently. The inspector spoke with a resident who confirmed that they are able to visit the GP in private and staff will accompany on request. Ivy Cottage operates the nomad concise blister pack system of medication, and records viewed by the inspector were found to tally with drugs stored. Members of staff involved in medication administration have been trained in the safe handling of medication. Detailed records of drugs entering the home and returned are up to date. None of the service users currently living at Ivy Cottage self medicate. The medication procedure is easy to follow, details of medication taken and any possible side effects are accessible to all members of staff with the medication records. The recommendation issued at the last inspection regarding the storage of medication within the food fridge has now been met. Medication administration records were sampled and drugs stored were found to tally. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents and support workers are confident that their views, concerns and comments will be listened to and acted upon. Residents are safeguarded and protected from self harm and abuse by the policies, procedures and practices governing adult abuse. EVIDENCE: Discussion with residents, support workers and management show that the home listens to what people say and takes action to correct things. During the visit to the home, the manager confirmed that there had been one complaint in the last twelve months. Records viewed during the inspection confirmed that this had been appropriately investigated and recorded, clear outcomes had been documented. A copy of the home’s complaints policy was on display within the home and also within the Service User Guide. Out of 9 resident questionnaires returned to CSCI all but one knew who to make a complaint to should the need arise. Staff training records viewed confirmed that all staff are provided with adult protection training and regular updates. The manager added that, should staff need guidance on how to use the in house procedure, this would be provided Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 16 to them. Staff spoken to during the inspection had a clear understanding of both the in house adult protection procedure and that of the Local Authority. At the time of the inspection the home did not have any outstanding adult protection alerts. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a welcoming and homely environment that is well maintained and appropriate to their needs. Infection control measures within the home ensure the wellbeing of both residents and staff. EVIDENCE: Ivy Cottage is suitable for its intended purpose and is safe and accessible for the all residents currently residing at the home. The communal rooms are well decorated and furnished, providing a homely and inviting atmosphere. On the day of the inspection the home was clean and tidy and no offensive odours were present. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 18 Seven resident questionnaires returned to CSCI following the inspection indicated that the home is always fresh and clean. Residents spoken to said that they were pleased with the newly decorated communal rooms. Staff spoke of creating tactile pictures and decorations specific to the individual preferences of each resident. One resident spoken to said that they were happy with their newly decorated bedroom and spoke of being involved in choosing the wallpaper and soft furnishings. All recommendations issued at the last inspection regarding the environment have now been fully met. Staff training records indicated that all staff undertake infection control training upon commencing work at the home. Throughout the inspection, staff were observed maintaining good standards of infection control through the use of gloves, aprons and cleaning solutions. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by a competent and qualified staff team. Residents are protected by the staff selection and recruitment policies and practices. EVIDENCE: Staff training records examined identified that all staff receive mandatory training upon commencement of their employment. In addition to this, staff undertake disability awareness, equality and diversity and service users’ specific training. The home operates a computer system which flags up when refresher training is due in order for this to be organised and ensure the level of care residents receive is not compromised. All resident questionnaires returned indicated that the staff treat them well all of the time. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 20 Staff files viewed contained all of the relevant information including criminal records bureau checks and references. The registered manager spoke of the recent changes to the home’s recruitment policy. Residents are now actively involved in the recruitment and selection process for all new members of staff. A copy of this policy was viewed and was found to be written in an appropriate format for the residents to follow, and has been well thought out to ensure the necessary levels of support from existing members of the care team can be provided. The home has access to both external and internal training through Acton Ltd. The manager explained that the home has access to an adequate training budget to ensure all staff have fair access. The home places great emphasis on staff undertaking an NVQ award and, at the time of the inspection, over 50 of staff had obtained this award. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from living in a well run home where they know their views will be listened to and influence what happens in the home. Residents are actively involved in the quality monitoring of the service. Residents and support workers are safeguarded by the home’s policies and procedures regarding health and safety. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 22 EVIDENCE: The service continues to be well managed and run in the best interests of the residents and staff. The registered manager plays an active role within the home and operates an open door policy for both residents and staff. This enables residents and staff to air any views or concerns they may have in order for solutions to be found and for the home to continue to move forward. Acton Ltd operates regular quality assurance checks within the home to ensure residents receive a good quality service. The home confirmed that CSCI inspection reports are used to highlight areas that require improvement. Resident meetings are held on a regular and minutes are available upon request. The manager makes sure that, so far as is reasonably practicable, the health, safety and welfare of residents and staff is promoted. Information sent to the Commission prior to the inspection identified that regular fire drills take place and regular safety checks are made on electrical and gas appliances within the home. All staff undertake regular manual handling and risk assessment training. Portable appliance testing is undertaken on a regular basis and all fire safety equipment has recently been inspected. Policies and procedures are regularly reviewed and amended as necessary. Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 23 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 3 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 24 No 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. Refer to Standard Good Practice Recommendations Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Brighouse Area Office Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Ivy Cottage DS0000006269.V309060.R01.S.doc Version 5.2 Page 26 - 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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