Inspection on 13/04/07 for 509 Leeds and Bradford Road

This inspection was carried out on 13th April 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 9 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

509 Leeds and Bradford Road 06/12/05

509 Leeds and Bradford Road 30/06/05

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 MIXED CATEGORY MAJORITY ADULTS 18-65 Leeds and Bradford Road 509 Leeds and Bradford Road Bramley Leeds LS13 2AG Lead Inspector Valerie Francis Key Unannounced Inspection 13th April 2007 10:40 Leeds and Bradford Road DS0000062102.V336095.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 Leeds and Bradford Road DS0000062102.V336095.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 Older People and 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. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leeds and Bradford Road Address 509 Leeds and Bradford Road Bramley Leeds LS13 2AG 0113 2040018 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) www.sense.org.uk Sense, The National Deafblind and Rubella Association vacant post Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2), Mental disorder, excluding of places learning disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (2), Physical disability (1), Sensory impairment (3), Sensory Impairment over 65 years of age (2) Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th December 2005 Brief Description of the Service: Leeds and Bradford Road is a converted period property. It provides accommodation on three floors for up to five younger adults or older people of both genders with multiple disabilities including sensory impairments. The house provides level access to the front of building. The rear is not accessible to people who have a physical disability, the garden is on two levels giving people who are physically disabled the opportunity to sit out and enjoy the garden in the good weather. A passenger lift is fitted to the first floor providing people with access to the ground and first floor. The people who use the service are provided with single rooms. Additionally, there is a large dining kitchen and lounge provided. Public transport is situated close by and there is parking available on road. The house is owned and managed by SENSE North a voluntary, national organisation that aims to provide housing and services with sensory needs. Fees paid are £1224 and £1744 per week. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report brings together evidence gathered at this first Key unannounced Inspection visit to Bradford Road the 13th April 2007 at 10.40 am by one inspector over a period of 6.5 hours. The inspection was concluded with feedback to the manager and the deputy manager on the 16th April at 9am over a period of 2 hours. In April 2006 the Commission for Social Care Inspection (CSCI) made some changes to the way in which care services are inspected. Care services are now judged against outcome groups. The inspection report is divided into separate sections for each outcome group for example Choice of Home. An overall judgement is made for each outcome group based on the findings of the inspection. The judgements reflect how well the service delivers outcomes to the people using the service. The judgements categories are “excellent”, “good”, “adequate” and “poor”. The judgements are recorded within the main body of this report. More detailed information about these changes is available on our website – www.csci.org.uk The staff advocating for the people living at the home have requested that the term “people who use the service” is used therefore this will be used throughout the report. The newly appointed manager, Mr Ciaran Wyer, was on leave, the deputy manager Julie Matthews was available to be involved in the inspection process throughout the day to answer questions, supply records and other information. The home completed a pre- inspection questionnaire before the inspection, which was returned to the CSCI area office before the inspection. The document provided information such as, review dates of policies and procedure and rate of fees. During the inspection, records were looked at, care staff were observed carrying out their work, and a tour was made of the building. People who use the service, staff, and the manager were spoken with throughout the day. Two of the four people who use the service were case tracked. Case tracking is the method used to assess whether residents receive good quality care that meets their individual needs. The key standards from the Care Homes for Adults (18-65) National Minimum Standards were assessed. Questionnaires for the relatives of the people who use the service were sent to the home to be forwarded, prior to the inspection. Questionnaires were also sent to other health care professionals before the inspection. These provide an opportunity for people to share their views of the home with the Commission for Social Care Inspection (CSCI.) Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 6 At the time of writing this report the three relatives questionnaires had been returned, all indicating that they were satisfied with the way they were received at the home and that staff were good to their relatives. Those questionnaires from visiting healthcare professionals had not been returned. I would like to thank the manager deputy manager, the people who use the service and staff for their assistance in the inspection process, and relatives who took the time to complete survey questionnaires and shared their views. Copies of previous inspection reports are available via the Internet at www.csci.org.uk. What the service does well: Staff provide people who use the service with good support and encouragement. Relatives said they are informed of any changes in the needs of their loved ones living at the home. The manager said advocates are used for people who do not have family to act on their behalf. The manager runs a home that is open, and was accessible to the people who use the service and staff. The people who use the service are encouraged to be as independent as possible and are given as much responsibility over their own lives, as they are able to accept. They are allowed to have friends and family visit as often as they like and are afforded privacy at these times. Staff encourage and enable people to pursue leisure activities. People are encouraged to take part in household activities and to take responsibility for certain tasks within the home e.g. their washing with staff support. Holidays are arranged for individuals as well as groups. The staffing numbers always allow for individual time to be spent with the people who use the service and outside agencies are involved to provide a more appropriate service. Meals are taken together and residents are involved in grocery shopping. One relative said, “ her relative is physically well cared for and there is a genuine affection shown from the carers she has met “she is in a wonderful family environment “. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 7 Relative commented “there is a great emphasis on stimulation through outings, shopping and visiting old friends” and believed that her relative had as full a life as possible. What has improved since the last inspection? What they could do better: The home must ensure that people who use the service and their family and friends must be involved (if that is what the service user wants) in their care planning. Planning for dealing with growing older, terminal illness and death and identified wishes must be recorded in the person’s plan. The registered provider must make sure that there is a policy and procedures available to staff on cleaning up of bodily fluids, such as blood. The registered provider must make sure that an application is made for the person employed at the home as the manager to be registered with the CSCI. Staff should have Equal Opportunity and the Disability Discrimination Act awareness training, so that they are aware of the legislation and a good awareness of the right of the people they care for. Additional ventilation or an extension to the existing one is needed in the laundry room. At the time of the inspection the room was very hot. The new pipes must be lagged, to stop them being a health and safety hazard to both staff and the people who use the service. PAT testing of electrical appliances must be done annually and a full electrical check must be carried out every five years. Risk assessment for the building must be carried out to identify any potential hazards with a plan in place how these would be minimised and managed. Discussion must be carried out with the environmental health inspector regarding the issue of fitting a fly screen to the window and possibly the door if they are open whilst meals are being prepared. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 8 All of the home’s information available to the people who use the service should be in a format and language appropriate to the needs of the people, so that everyone has access to understandable information. 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. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Adult 18-65 3 &6 Older people. People who use the service experience good quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. Information about the service is good but not readily available in a format people who use the service can understand. People who use the service can be sure that the home will meet their needs and aspirations following their assessment for admission. EVIDENCE: The home has a statement of purpose, which gives people who use the service and their carers/relatives detailed information on what to base their decision when considering moving into the home. However, although there is an opportunity to have the information in a different format that would assist the people who use the service to Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 11 understand the information, this is not readily available in the home, only on request. The Service User Guide was not available for inspection therefore the inspector is not able to comment on its suitability. There have been no admissions to the home since the last inspection meaning that the last admission was three years ago. The home has an admission policy and process in place that will be used whenever a vacancy does arise. At the time of this inspection there was one vacancy and another with the move of one of the people using the service to a nursing home. An assessment of need was done on all the present people living at the home prior to their admission plus the input from social and/or healthcare workers. All of the people who use the service and their relatives can be sure that needs and aspirations are met at the home. The staff are trained to work with people who have a sensory disability and showed a good understanding of their needs. They encourage the residents to live as independently as possible and offer the appropriate support to allow them to fulfil their ambitions. However, there was no evidence if to show that staff at the home have had training to meet the needs of people who use the service with learning disability. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 12 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14 and 33 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 (adults 18-65) and 7, 14 and 33(older people standard). People who use the service experience good quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. Records accurately reflect the needs of the people who use the service and highlight any areas of risk. There was no written evidence to support that people’s relatives and others’ are involved in their care planning process. EVIDENCE: People who use the service have a full (PCP) person centred plan which reflects their change in care needs. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 13 Two people’s care files were inspected; it was evident that evaluations and reviews are carried out. The people presently living at the house were not able to fully assist in the care planning process. The manager said that relatives/ carers are invited to attend planning meetings. New care plans are made following the planning meeting, a copy of which is sent to relatives for their agreement. However there was no evidence seen on any in the care file seen that relative’s or people had an input in the care planning process. The inspector was told that documentation was sent to relative a week before the PCP’s review. Both PCP seen had information on health reviews and social care and development. They both had good information written in the first person, all care needs had a plan on how they would be met with in some cases the involvement of outside agencies and health care professionals. It was evident that the care provided was in accordance with the wishes of the individual. Each person has a key worker and they are responsible for making sure care plans, risk assessments and reviews are up to date. A daily log of events for each person is made in the home’s communication book. Advice was given that any records made about a person should be logged in their file. Risk assessments are carried out and the home responds quickly to matters concerning the people who use the service. Any risk identified has supporting information on how the risks are managed and minimised. Advice was given that risks for day to day living should also be assessed. The files are in a lockable filing cabinet and confidentiality takes a high priority at the home. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 14 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. Service Users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. Service users find the lifestyle experienced in the home matches their expectations and preferences and satisfies their social, cultural, religious and recreational interests and needs. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers Standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 15 12,13,15,16 & 17 (Adult 18-65) and 10,12,13 & 15 (Older people). People who use the service experience good quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. The home offers a wide range of activities based on the residents’ choices and abilities. They are given opportunities for their own development and encouraged to take advantage of these. A good, healthy and varied diet is served at the home. The omission of a written nutritional assessment could put some people at nutritional risk. EVIDENCE: There is an activity co-ordinator employed, who arranges outings and social activities individually or as a group for people who use the service. During the course of the inspection it was evident that people go out supported by staff to places of their interest, e.g. going shopping in the local shopping centre. The information in the communication book and peoples care files confirmed that regular outings and activities are arranged. Activities are arranged with the home and other agencies such as day centres. It was evident from relatives survey information, that they are given the opportunity to visit their relative at the home. People are encouraged to make new friends with people outside of the home, who they can also invite to visit. During the visit, one of the people who use the service wanted to go out for a walk to the local shopping centre, this was quickly arranged with her key worker. The manager and staff feel that social activity for the people who use the service is an important part of people’s life. Relatives also indicated that they were happy with the amount of stimulation and activities their relatives were receiving. People are involved in activity within the home such as listening to music, artwork and watching television or videos. People have a holiday at least once a year to suit heir individual needs. There is a big emphasis on choice and rights, which are advocated by staff, people are asked their choice of room where they would like to spend their time and where they preferred to sit. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 16 Menus are pre-planned at the home. However, if a person wanted something different to what is on the menu, this can be done. A good variety of food is available and staff try to make sure there is a good selection of fresh produce available. Staff does menu planning with the involvement of the people using the service, the home places this as a high priority and all staff makes sure this happens. People likes and dislikes and choice of food are discussed and through observation at meal times at the home and when they eat out. There was no written evidence that a nutritional risk assessment is carried out to make sure that people nutritional needs are assess. The knowledge of the people is use to assess their nutritional needs. This could mean that people’s nutritional needs could be overlooked. Weight checks are carried out but not as regularly as the home would like because they are dependent on the use of an outside agency chair scale. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 17 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 & 20 (adult 18-65) 8,9 & 10 (older people). People who use the service experience good quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. Personal care is given to people who use the service in a way that respects their ability and choice. People’s health care needs are met. EVIDENCE: Personal care is provided in a polite way, people are encouraged to choose their clothing, a good level of support is given when shopping for new clothes, Staff provide people with a good level of support which take into account their choice. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 18 There was evidence in people’s health care records that their health care needs are met. There is an annual health care and medication review, the deputy manager said staff have good working relationship with health care professional who they an access for any advice or issue they may have with regards to people’s health care. When people need to see their General Physician visits are made to their surgery, home visits are made in emergency or if people were unwell then a home visit will be requested. In discussion with staff they demonstrated clear understanding of the care needs of the people in their care. Staff follow correct procedures when ordering and administering medication. There is a record book of all medication received in the home and a duplicate book for all returns which is signed by the member of staff carrying out the transaction with a signature of the pharmacist receiving it. Thus providing clear audit trail. All staff have had one day training in safe handling of medication within their induction course. There is an assessment questionnaire which is completed by the staff and assessed by the manager to make sure staff are competent to administer medication. Medications are kept in a drawer in a locked filing cabinet, keys are not kept on any person, a recommendation made that these keys should be kept on the person in charge. A care plan of the last wishes was not in place, the only information available on the PCP for last wishes relates to after death arrangements. A recommendation is made that a plan should be in place for people on the care for their end of life. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 19 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 (adult 18-65) and 16,18 & 35(older people). People who use the service experience good quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. Concerns and complaints are taken seriously and people who use the service are protected by a strict adult abuse policy. EVIDENCE: Staff were able to explain how they would deal with a complaint, and were clear about how they would respond to any allegation or suspicion of abuse. The home has policies and procedures in place relating to complaints and adult abuse, and contact details for the adult protection team are available in the office. Although a copy of the organisation’s complaint procedure is available to prospective users and relatives, the format does not allow the people who use the service to have the opportunity to use the procedure without a lot of input from staff. So that everyone has access to understandable information. Staff receive safeguarding in adults training as part of their induction training. During discussion with staff it was clear that they have a full understanding of the procedure and what to do if an allegation of abuse occurred. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 20 During the discussion it was clear that they were aware of the whistle blowing policy procedure and would have no problem using it. Staff have had a two day training on non-violent crisis intervention within three months of employment, which is reviewed annually, this was supported by the organisation policy and procedure on intervention. Relatives responding to the survey indicated that they would have no hesitation in making a complaint. However, not all knew the procedure to follow if they had a complaint, but they would approach the manager in the first instance. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 21 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 (Adult 18-65) and 19 & 26 (Older people). People who use the service experience adequate quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. The environment is comfortable for the people who use the service and provides appropriate toilet and bathing facilities. EVIDENCE: Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 22 The home is decorated and furnished to a satisfactory standard. It is acknowledged that all effort is made by staff to keep the home in a good order of repair and redecoration. The communal sitting room does not offer sufficient of space to accommodate all the people living there or group activities. Some people choose to sit in the dining kitchen, however there are no comfortable chairs for them to sit on. The passenger lift only goes to the first floor, which restrict people with poor mobility to have a bedroom on the second floor. People have chosen the decoration for their bedrooms and have personalised them with their own possessions. The bedrooms are very much their own space and the residents’ privacy is respected and maintained. Wheelchair access is only to the front of the building. The Bathroom decorations are showing signs of wear and tear. There are sufficient baths in the home to meet the needs of the residents. Since the last inspection a new Jacuzzi bath has been installed some of the aids in the bathrooms had been removed, the deputy manager said these were to be refitted so that people have the equipment they need when using the facilities. Toilets are available in different areas of the home and bathrooms. The home was clean and tidy throughout and there were no unpleasant odours present. There is a budget for redecoration and replacement of furniture and fitments. One of the people living there had the appropriate moving and handling equipment to assist staff to move him. The laundry room is fitted with a sluice cycle washing machine and a dryer, some of the people who use the service are supported to carry out their own washing. Since the last inspection an additional boiler has been installed in the laundry, this has cause the room to be overly warm and the existing ventilator appear not to be appropriate for the hot air in the room, recommendation was made that the organisation should consider fitting a larger vent to this area, and covering the exposed hot pipes. Although staff have had infection control training as part of their induction, and there was an infection control policy procedure, there was no written procedure in place on safe handling clinical waste and to deal with spillages, such as bodily fluids. Discussion must be carried out with the environmental health regarding the issue of fitting a fly screen to the window and possibly the door if they are open whilst meals are being prepared. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 23 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 & 35 (Adult 18-65) and 27,28 29 & 30 (older people). People who use the service experience good quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. Recruitment practices protect service users. There is a good level of training provided that is appropriate to the needs and conditions of the people who use the service. EVIDENCE: Throughout the inspection there were sufficient staff on duty to meet the needs of the people who use the service. Staff said that they had plenty of time to spend with the people who use the service. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 24 There is good communication within the home and staff meetings take place regularly. The manager and deputy said the daily staffing levels are in place to reflect the activities to be undertaken by the people who use the service. Which could mean that there is as much as five staff in the house to support people, this could included any specialist staff that would be brought in to meet individual needs. There are two staff in the house during the night, one awake and one sleeping. The deputy said the sleeping in person is there to assist the wake staff in an emergency and if there was a communication problem with a person. The recruitment files of two recently appointed staff were sampled and both contained completed application forms, two written references, photograph, successful criminal record bureau/protection of vulnerable adults disclosures, offer of employment and contract of employment. The manager and deputy said that when recruiting new staff they look for people that have good communication skills as this is essential when working with the people who use their service. So that staff are clear of their code of conduct and practices each person employed should be given a copy the (GSCC) General Social Care Council code of conduct. Information supplied in the pre-inspection questionnaire shows that most staff have undertaken training on food hygiene, health & safety, safe use of medication, moving and handling, basic first aid, protection of vulnerable adults and non-violent crisis intervention. There was no evidence that there was a training plan in place, other than the organisation’s repeat courses for moving and handling and first aid. There is on going training in place to make sure all staff have an NVQ qualification (National Vocational Qualification). Staff at the home had not received any training on equal opportunity or disability awareness, which would provide them with information on the rights that affect the people in their care. The deputy said training and development is discussed at their annual appraisal meeting and one to one supervision, which is held every four to six weeks with either the manager or the deputy. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 25 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. Service users live in a home which is run and managed by a person who is fit to be in charge of good character and able to discharge his or her responsibilities fully. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39 & 42 (adult 18-65 and 31,33,35 & 38 (older people). People who use the service experience Adequate quality outcomes in this area. We made this judgment using a range of evidence, including a visit to the service. The home management arrangement appears to be suitable,but the health and safety of the people who use the service is not always protected. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 26 EVIDENCE: The manager has only been in post since January 2007, no application has been made to the CSCI for him to become the registered manager for the home. He has over four years experience in management obtained whilst working as a deputy manager at another service. He has undertaking the Registered Managers’ Award course completed training on blinddeaf, and other related courses. There are plans in place for him to undertake NVQ 4 in care. He said that he has good support and supervision from his line Manager, he is enthusiastic and confident in his role, and has started delegating some management tasks to the deputy manager. Staff appeared to find him approachable. The manager said that staff, family and other interested parties are surveyed and a self assessment form sent to the home annually by the policy and quality unit in the organisation to measure and monitor the home’s success in meeting its aims and objectives. A copy of the outcome should be sent to the CSCI area office. A recommendation has been made. Weekly health & safety checks are carried out and the pre-inspection questionnaire identified that necessary checks and servicing takes place as required. Fire alarms are tested weekly and a record is kept of any action needed, for example a door not closing properly. It was not known if the electricity safety check had been carried out in the last five years, as a copy of the safety certificate was not available. Risk assessments for the building had not been carried out with any potential identified risk highlighted with a plan how they would be minimised and managed. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 27 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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 2 4 3 3 4 3 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 2 STAFFING Standard No Score 31 X 32 2 33 4 34 2 35 2 36 3 CONDUCT AND MANAGEMENT Standard No Score 37 2 38 X 39 2 40 2 41 X 42 2 43 X 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 X 15 4 16 4 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Leeds and Bradford Road Score 4 4 3 X DS0000062102.V336095.R01.S.doc Version 5.2 Page 28 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 YA21 Regulation 12, 13 & 15 Requirement Timescale for action 31/07/07 YA24 2. 23 (5) 3. YA42 23 The service users and their family and friends must be involved (if that is what the person who use the service wants) in planning for dealing with growing older, terminal illness and death. Identified wishes must be recorded in the service user plan. Timescale agreed at the last inspection 01/02/06. Discussion must be carried out 30/07/07 with the environmental health regarding the issue of fitting a fly screen to the window and possible the door if they are open whilst meals are being prepared. Information must be sent to the CSCI area office. 14/07/07 Additional ventilation or an extension to the existing one is needed in the laundry room. At the time of the inspection the room was very hot. The new pipes must be lagged, to stop them being a health and safety hazard to both staff and the DS0000062102.V336095.R01.S.doc Version 5.2 Leeds and Bradford Road Page 29 4. YA42 23 5. YA42 23 people who use the service. PAT testing of electrical 14/07/07 appliances must carry out yearly. A full electrical check must be carried out. A response must be sent to the CSCI area office. Risk assessment for the building 14/07/07 must be carried out to identify any potential hazards with a plan in place how these would be minimised and managed. Any potential risk to the people who use the service or staff when they are out, must be risk assess with a plan in place in people who use the service PCP’s. The registered provider must make sure that there is a policy and procedures available to staff on cleaning up of bodily fluids, such as blood. A copy must be sent to the CSCI office. 31/07/07 6. YA9 4 (b) 7. YA42 16. 23 (3) 31/07/07 8. YA37 8 (2) 9. YA35 18 (i) The registered provider must 30/07/07 make sure that an application is made for the person employed at the home as the manager to be registered with the CSCI. Staff must have Equal 31/07/07 Opportunity and the Disability Discrimination Act awareness training. So that they are aware of the legislation and a good awareness of the rights of the people they care for. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 30 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 YA29 Good Practice Recommendations Chair scales should be provided or use of chair scales within another facility ensured in order to accurately monitor an individuals weight. All of the home’s information available to the people who use the service should be in a format and language appropriate to the needs of the people wanting to use the service and those who live in the home, so that everyone has access to understandable information. Staff should have further training on safe handling of medicine, so that they have more information on the matter. Relatives and others should be provided with a copy of the organisation’s complaint procedure so that they know what procedure to follow if they had a concern/ complaint. The bathrooms decorations are showing sign of wear and tear and needs redecorating. Staff must be given a copy of the GSCC code of conduct, so that they comply with standards of conduct and practice. 3. YA1 4. 5. 6. 7. YA20 YA22 YA24 YA31 Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 31 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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. Leeds and Bradford Road DS0000062102.V336095.R01.S.doc Version 5.2 Page 32 - 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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