Inspection on 24/01/07 for Lees Hall Road

This inspection was carried out on 24th January 2007.

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

Lees Hall Road 07/03/06

Lees Hall Road 28/04/05

Lees Hall Road 23/11/04

Lees Hall Road 07/09/04

Lees Hall Road 13/01/04

Lees Hall Road 08/09/03

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

CARE HOME ADULTS 18-65 Lees Hall Road 333 Lees Hall Road Thornhill Lees Dewsbury West Yorkshire WF12 ORT Lead Inspector Helen Battle Key Unannounced Inspection 24th January 2007 12:15 Lees Hall Road DS0000026347.V315877.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 Lees Hall Road DS0000026347.V315877.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. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lees Hall Road Address 333 Lees Hall Road Thornhill Lees Dewsbury West Yorkshire WF12 ORT 01924 459689 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.st-annes.org.uk St Anne`s Community Services Mrs Elaine Anne Firth Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Lees Hall Road is a registered care home that provides support for up to 8 adults who have a learning disability with emotional disorders, mental health issues, have offended or have the potential to offend. The purpose of the home is to support people to move on to alternative, appropriate accommodation. The home is part of St Anne’s Community Services. There are six single bedrooms and a self-contained flat and bed-sit for one of the service users, plus a staff sleep-in room and office. There is a large kitchen and separate dining area. There are also two lounges; one is used as a quiet area and/or games room. Lees Hall Road is a purpose built detached house and has a large garden where service users are able to sit out or help with gardening. The home is located within close proximity of bus and train services and there are local shops and medical facilities within walking distance. The Provider informed the Commission for Social Care Inspection on 24 January 2007 that the top up fees range from £301.83 to £308.32 per week. Information about the home and the services provided are available from the home in the Statement of Purpose and Service User Guide. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of this full inspection, a visit to the home took place. The inspector visited the home unannounced from 12.15 hrs to 16.30 hrs. Whilst at the home, key documents such as care assessments, care plans, daily records and staff records were looked at, and so were some of the rooms and the garden. Three members of staff were spoken with, along with the manager. Four service users and one visitor were spoken with. The manager had been asked to complete a pre-inspection questionnaire. This was returned to the Commission prior to the visit taking place. Comment cards were sent to service users, their relatives, visiting professionals and GPs. There were five service users living at the home at the time of this visit. Two surveys were returned from GPs and three from healthcare professionals. All these responses were positive. Comments included “very caring, competent staff” and “the staff give excellent support to my client, they are always available for information. They provide an excellent service in my opinion”. What the service does well: What has improved since the last inspection? There is now a risk assessment regarding the management of medicines when service users are on social leave. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Lees Hall Road DS0000026347.V315877.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 Lees Hall Road DS0000026347.V315877.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. Service users have their individual needs assessed prior to admission into the care home. EVIDENCE: Service users have information to help them make an informed choice about where to live. This is in the form of a user-friendly Service User Guide, with illustrations to help service users understand the guide. Service users have their individual needs assessed prior to admission into the care home. Pre admission assessments of three service users were seen and contained relevant information. Lees Hall Road DS0000026347.V315877.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, 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Plans of care are in place and service users are able to see their plan. Service users make decisions about their lives and take risks as part of a more independent lifestyle. EVIDENCE: The care plans of two service users were examined. These reflected the current needs of the service users. The care plans had been reviewed and there was information regarding the involvement of other healthcare professionals in meeting the needs of the service user. There was evidence of service users being involved in the formulation and review of their care plans. Entries in the daily records were detailed and gave a good account of what support had been delivered on a day-to-day basis. Records regarding the management of challenging behaviour are particularly well documented. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 10 It was clear from speaking to staff and service users, and from reading care records, that service users are encouraged and supported in making decisions about their own lives. Any risks are outlined to service users and a risk assessment carried out. Lees Hall Road DS0000026347.V315877.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, 14, 15, 16, 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users take part in appropriate activities and are part of the local community. Appropriate relationships are maintained. Service users’ rights and responsibilities are respected. Meals provided at the home are of a good standard. EVIDENCE: Service users take part in a variety of activities suitable for their development. These include going to college, working, sports, shopping, going out to places of interest such as Tropical World in Leeds, and going out with friends and family. The artwork of one service user is displayed in the home. Games, quizzes and a computer are available in the home, and a football net is reported to be well used in the better weather in the garden. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 12 It was reported that service users would like a pool table in one of the lounges. On the day of this visit, some of the service users went to a local sports centre to play badminton. This was facilitated by an occupational therapist and was part of an eight week programme where service users have been supported to participate in a variety of sports and activities. It was evident from speaking to service users on their return that they had enjoyed the afternoon. One service user spoke about playing chess with staff and that they enjoyed going out walking. The gardens are easily and freely accessed by service users. Service users were seen to be treated with respect and their privacy and dignity maintained by staff during this visit. Service users are supported to maintain links and relationships with friends and family where possible. Service users spoken to stated that they are allowed to see visitors at any time and the home has evidently worked hard with service users to support them with maintaining relationships. The meals provision at the home is good. Feedback from service users was very positive. Lees Hall Road DS0000026347.V315877.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, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users receive support in a way they prefer and require. Emotional and health needs are met. Service users are protected by the home’s policy and procedure for dealing with medication. EVIDENCE: Service users spoken to stated that the staff are kind and support them in a manner which promotes privacy and dignity. Service users also stated that they are able to choose what times they get up and go to bed. There was evidence in the records of service users that support is also provided from specialist healthcare professionals. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 14 The medication of two service users was checked and were found to tally with the records held. A risk assessment has been carried out and a policy introduced regarding the management of medication when service users are on social leave. A staff signatory list is in place for those staff designated to administer medication. Lees Hall Road DS0000026347.V315877.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, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. EVIDENCE: The service users spoken to felt that they could speak to any member of staff and that they would be listened to. There have been two formal complaints made to the home since the last inspection. These were fully investigated within given timescales and records held regarding these complaints and the action taken. The complaints procedure is given to all service users at the time of them of moving into the home and their advocate goes through this with each individual to ensure their understanding. The majority of staff have received adult protection training, however, the training records show that some staff may not have received this training for some time. It was evident from speaking to staff, and from their action regarding adult protection matters, that they are fully aware of policies and procedures and that they work within them. The personal monies of two service users were checked and were found to reconcile with the records held. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 30. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Generally, the service users live in a comfortable and safe environment. The home is clean and hygienic. EVIDENCE: Service users were enthusiastic in speaking about their rooms and how they were personalised. One service user showed photos of their room and spoke about their possessions. The flat in the home has been refurbished with a new kitchen fitted. A new floor was to be fitted the day following this visit. New furniture has also been ordered. The large lounge has recently been decorated, however the sofa and carpet are stained and should be replaced. The rest of the home is well maintained and homely and is clean and hygienic. The gardens are also well maintained, one of the service users has helped in looking after the gardens. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 17 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, 35. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users are supported by competent and qualified staff. Service users are protected by the home’s recruitment practices. Not all staff are receiving mandatory training within recommended timescales. EVIDENCE: Staffing levels are provided to meet the needs of the service users living in the home. Although all staff have received mandatory training, not all have had up to date refresher training in key areas. Training has been requested and training records evidenced this, however training sessions have not always been readily available for staff to attend. There was no evidence to suggest that any practice is compromised. NVQ training is also continuing at the home with seven members of staff having achieved NVQ level 3, one member of staff awaiting certification for NVQ level 4, one member of staff with a Diploma in Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 18 Social Science and one with a degree in social care. All new members of staff receive a full induction, records were seen to confirm this. The recruitment process at the home protects the service users living at the home. The records for two members of staff were examined and had the required records and checks in place. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users benefit from a well run home. Service users’ views underpin development at the home. The health, safety and welfare of service users is generally protected. EVIDENCE: The manager of the home, Elaine Firth, has good experience in looking after this service user group and has recently completed the NVQ level 4 award. She is currently awaiting certification for the award. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 20 Service users’ views are listened to and underpin any development of the home’s policies and practices. Monthly management visits are carried out and the organisation carries out annual quality audits. This includes seeking the views of the service users via a survey. There were no apparent health and safety issues observed during this visit. Weekly tests of the emergency lighting and fire alarm systems are recorded. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 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 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 2 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 2 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 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 22 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. 1. 3. Refer to Standard YA24 YA35 Good Practice Recommendations The carpet and sofas in the large lounge should be replaced. All staff should receive core refresher training within recommended timescales. Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND 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 Lees Hall Road DS0000026347.V315877.R01.S.doc Version 5.2 Page 24 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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