Inspection on 28/04/05 for Lees Hall Road

This inspection was carried out on 28th April 2005.

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 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 24/01/07

Lees Hall Road 07/03/06

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 WF12 ORT Lead Inspector Jim Leyland Unannounced 28 April 2005 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 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 Stationary 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 J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Lees Hall Road Address 333 Lees Hall Road Thornhill Lees Dewsbury WF12 0RT 01924 459689 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) St Annes Community Services Mrs Elaine Firth CRH - Care home only 8 Category(ies) of 8 x Learning Disability registration, with number of places Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 23 November 2004 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. Annes Community Services. There are six single bedrooms and a self-contained flat and bedsit 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. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection started at 2pm and finished at 7pm. Discussion took place with 6 of the residents and five members of staff; the manager were also spoken to. A tour of the home took place and two staff files, three residents’ care plans and activities, health and safety, complaints and training records were examined. Residents participated in various activities on the day of the inspection, including attending college, playing football and gardening. Residents said that they found staff to be supportive and could speak to them at any time. One resident was enthused about writing an article for a newsletter for the home and another was looking forward to a weekend away with their family. One requirement about ensuring regular fire drills and good practice recommendations relating to health and safety, medication and the TV aerial in the home are made. Thank you residents, staff and manager for your assistance and input to this inspection. What the service does well: What has improved since the last inspection? Environmental improvements are being made in the home, after taking into consideration the views of residents. Following a previous recommendation a list of authorised signatories for staff administering medication has now been provided. There has been a significant amount of progress by the staff team to engage some residents in meaningful and fulfilling activities. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 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. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 The home is able to demonstrate that the needs of residents, who are admitted to the home are assessed comprehensively, by people qualified to do so. EVIDENCE: Two resident’s files were examined at the inspection visit. The needs of a recently admitted person had been comprehensively assessed before they commenced their placement at Lees Hall Road. The manager said that the relevant information had been provided, including the details relating to the Care Programme Approach and statutory orders. These set out an individual care plan and appropriate risk assessments. A second case file was examined and contained a community care assessment for the resident, carried out by a social worker. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8 and 9 The individual care plans for residents provide an inclusive documentation, setting out how the needs and goals will be met. Residents are involved in the decision-making process, through regular meetings and support from advocacy services. Risks are identified and appropriate risk management plans are devised. EVIDENCE: The manager pointed out that an individual plan was in the process of being devised for one resident. A comprehensive discharge assessment has been undertaken and staff are aware of the person’s needs. Evidence was seen that a person-centred approach is used and residents are involved in helping to devise their care plans and set out goals. The plans explain what support and/or intervention is/are required from the staff team. Where residents are on the Care Programme Approach, regular multi-disciplinary review meetings take place in order to ensure that their needs can be met at Lees Hall Road. There was clear evidence that residents’ needs and compatibility issues are monitored closely and that consideration with social services and health professionals about future placements are discussed with residents, as these needs change. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 10 Many of the residents at the home said that they had access to advocacy services and some saw their advocate on a regular basis to enable them to voice any worries and express their views. One resident said that they were able to bring up a variety of issues at the residents’ meeting, making decisions about issues in the home and talking through any ideas, concerns or suggestions, informally. A member of staff said that they had been supporting a service user to attend the St. Anne’s management board, to promote inclusion and partnership work when making decisions within the organisation. One service user said that they had produced an article for a newsletter in the home, promoting a sense of ownership. The home has ‘Tell us what you think’ questionnaires to gauge views from residents. Risk assessments explain where there is any limitation on choice or human rights and are used to balance independence and protection. Staff at the home have shown their ability to identify risks and potential danger and a recent example showed that their prompt actions and involvement of relevant agencies has minimised the risks identified. The assessments set out the identified risk, what actions staff need to follow and any interventions required. The risk assessments have been reviewed on a monthly basis and any changes to them are recorded. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 15, 16 and 17 Residents living at Lees Hall Road are supported and encouraged to participate in fulfilling and meaningful activities, tailored to their needs and wishes. Links with families and friends are maintained and staff are aware of any restrictions or concerns about such visits. Residents have their rights respected and have their own responsibilities and routines. A healthy diet is offered, taking into consideration special dietary requirements and choice. EVIDENCE: On the day of the inspection, occupational therapists were visiting the home and supporting three of the residents with planting and developing their garden. As part of their input, the occupational therapists have fully involved the residents, asking them what kind of activities they would like to do through planning meetings. A walking group has commenced each week and residents said that they had enjoyed this and where they had been to. Staff have supported residents to tap into various therapeutic activities in the area, for example acupuncture, aromatherapy and hydrotherapy ton promote relaxation. Additionally residents explained that they also attended college, Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 12 undertook voluntary work, went to a local gym, attended local social groups and projects and one said that they played football for a local team each week. Three service users said that they maintained regular contact with members of their family. One said that they were looking forward to spending a weekend with their family; another said that they were able to maintain their relationship with the person of their choice, after moving to the home. Staff are aware of any restrictions or risks associated with visits to and from families and friends and these are documented in the appropriate care plans. The rights of residents in the home are promoted. One person pointed out that they had their own key for their bedroom, but was aware that when they went out that they need to be escorted by a member of staff for their own and other’s safety. Residents open their own mail and have general household tasks and chores to do, promoting responsibility. There was evidence that residents are able to choose when to be alone or in company. Special dietary and cultural requirements are set out in the relevant care plans. Staff support and encourage residents to follow any diets and offer advice and suggestions. One person has input from a practice nurse concerning their diet and the manager said a dietician would be referred to if this became necessary. On the day of the inspection the inspector had tea with the residents. One of the people who lives in the home had helped to prepare the meal. The meal was served in a congenial and relaxed setting. Residents can choose an alternative and all help to prepare a menu for the week ahead. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 Where residents require assistance with personal care, their privacy and preferences are considered. The home liaises closely with various agencies in order to promote the health and emotional well being of residents. The home has a satisfactory medication system in place and a suggestion is made relating to ensuring that recording is accurate. EVIDENCE: Individual care plans set out guidelines on residents’ needs and preferences relating to personal support. One care plan set out that the individual’s needs to be prompted to promote personal hygiene. Residents are able to choose what time they get up and go to bed and whether or not they have a bath or a shower. Advice and support from health and social work professionals is sought in order to provide residents with appropriate input relating to developing their independence and self-care skills. Each resident has been registered with one of two local GP practices. All residents receive an annual ‘OK Health check’, setting out details about their health, medication and which health professionals are involved in providing support. One resident had a Health Action Plan in their care plan, setting out clear guidance about how to support residents’ mental health problems. The health needs of residents at Lees Hall Road are reviewed appropriately and input from psychiatrists, psychologists, occupational therapists and other Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 14 professionals is documented. Residents said that they attended dental, chiropody and optician appointments when they needed them. The home uses the Boots Monitored Dosage System for medication and all staff who administer medicines have received the relevant training. The medication of three service users was checked and the as required and prescribed medication balanced with the information on the Medication Administration Record. Residents’ files provide a record of current medication being taken. One good practice recommendation is made about the use of codes on MAR sheets. Where the code for social leave is used, the key should clarify whether or not medication has actually been administered. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has a clear and effective complaints procedure in place and residents feel that they are listened to. The procedures at Lees Hall Road are effective, protecting residents from harm and abuse. EVIDENCE: There is a complaints procedure at the home and residents are aware of how they can make a complaint. Where complaints are logged, details about the nature of the complaint, how the issue was settled, the need for further investigations, necessary actions and the outcome for the complainant are noted. The manager discussed one recent complaint, where advocacy services had been contacted to support a resident voice their concerns. The complaint was acted on appropriately and because there were some bullying and adult protection issues, relevant social workers were included to gauge risks for residents and look at their safety and work with the home to manage the situation. Incidents of self-harm are recorded, with referrals to appropriate health professionals and risk management plans devised. Residents’ finances are safeguarded through appointees and support from staff. Money is stored securely and residents have access to their money, unless a restriction is placed on them through a risk assessment. The money of two residents was checked and this balanced with the details recorded on the transaction sheet. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 28 The home is safe and comfortable. Poor television reception is causing some frustration. EVIDENCE: Lees Hall Road is a purpose built detached house, which has a large garden. During the inspection visit the home was found to be clean and tidy. Following a previous recommendation, the manager confirmed that a new sofa and armchair had been ordered for the main lounge. This has also been raised at a residents’ meeting. There area a number of communal areas in the home, one lounge offers a degree of privacy if a resident wishes to be alone. The recommendation remains however, that the manager look into ways of improving the picture quality of televisions in the lounges and bedrooms, following residents’ comments that the picture quality is poor and they cannot receive certain channels. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 34 The management and organisation operate a rigorous recruitment procedure in order to safeguard and protect residents in their care. EVIDENCE: The files of two recently recruited staff were checked at the inspection visit. Both contained the necessary information including an enhanced Criminal Records Bureau disclosure, two written references and photographs. All staff appointments are subject to a six-month probationary period. Where any concerns are identified, there is clear evidence that the manager works with staff and extends the probationary period if necessary. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 18 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 and 42 The systems for consulting with residents are good, with a variety of evidence that indicates that residents’ views are both sought and acted upon. The health and safety of residents is promoted, although more attention to regular fire drills and monitoring of refrigerator temperatures is necessary. EVIDENCE: Residents confirmed that they have received support to complete user satisfaction questionnaires from advocacy services. Minutes from a resident’s meeting highlighted that an advocate had assisted residents to voice their views about things that they would like for the home. The manager and some of the residents said that some of the issues have been dealt with, in order to promote quality assurance and outcomes for residents. The manager said that the organisation is looking at ways of incorporating the views of residents into the service user guide for Lees Hall Road. Staff at the home are up to date with their mandatory health and safety training. A requirement is made in relation to fire drills. Records show that Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 19 some staff have either not participated in a drill since they commenced employment or have not participated in a drill for over twelve months. All staff must be aware of the procedure to be followed in the case of a fire in the home. The inspector acknowledges that following the inspection visit, that more drills have been planned to ensure that all staff are involved in the process. In addition a recommendation is made that the refrigerator temperatures be monitored and a new thermometer be purchased due to fluctuating recordings. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 4 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x 2 x x Standard No 11 12 13 14 15 16 17 x 4 x x 3 3 3 Standard No 31 32 33 34 35 36 Score x x x 3 x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lees Hall Road Score 3 4 2 x Standard No 37 38 39 40 41 42 43 Score x x 3 x x 1 x J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 21 na 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 42 Regulation 23(4)(e) Requirement The registered person must ensure by means of fire drills at suitable intervals that persons working in the home are aware of the procedure to be followed in the event of a fire. Timescale for action 31st May 2005 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. 2. 3. 4. Refer to Standard 20 28 42 37 Good Practice Recommendations It is recommended that where the code on the MAR sheet for social leave is used, that the key should clarify whether or not medication has actually been administered. The manager should try to rersolve the problems with the aerial, which is affecting picture quality of the main television and service users portable sets. A new refrigerator therometer should be purchased due to fluctuating readings, in order to safeguard the health and safety of staff and service users. The manager should continue working towards her NVQ level 4 award, to ensure that it is achieved by the end of 2005. Lees Hall Road J51J01_s26347_Lees Hall Rd_v220494_280405.doc Version 1.30 Page 22 Commission for Social Care Inspection Park View House Woodvale Office Park Woodvale Road Brighouse HD6 4AB National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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