Inspection on 07/03/06 for Lees Hall Road

This inspection was carried out on 7th March 2006.

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 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 Unannounced Inspection 7th March 2006 1:00 Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 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) 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.V282472.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th April 2005 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. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by two inspectors and lasted 2 hours. Inspectors were able to speak to three residents, one visitor and two members of staff. Records examined included care records, training records, medication records and health and safety records. Inspectors looked round the communal areas of the home. Residents were taking part in various activities on the day of the inspection, including going to a country and western dance, entertaining visitors or attending work placements. The inspectors would like to thank the residents and staff for their warm welcome and hospitality during the visit. What the service does well: What has improved since the last inspection? Records of fire drills and medication administration have improved. The television reception is now satisfactory with the installation of digiboxes. A new fridge and fridge thermometer have been purchased as well as new furniture for one of the lounges. A new fire and fireplace is to be fitted in the near future. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 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 DS0000026347.V282472.R01.S.doc Version 5.1 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.V282472.R01.S.doc Version 5.1 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 the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 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 the following standard(s): 6, 7,9. Residents know that their individual and changing needs are reflected in their care plan. Residents are supported to make decisions about their lives and are able to take risks as part of leading an independent lifestyle. EVIDENCE: The care records of two residents were examined. These contained comprehensive information about the resident, their goals and achievements. Clear, realistic objectives are set with timescales and review dates. Daily records provide detailed information about how residents spend their day and how staff manage issues which arise. It was clear from speaking to residents and staff that residents are supported to make decisions about their lives, future plans and take risks with support and assistance from staff where required. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15 Residents are supported in accessing opportunities for personal development and in accessing appropriate activities. Residents are part of the local community and have appropriate personal, family and sexual relationships. EVIDENCE: Clear evidence was seen in residents’ care records, and from speaking to them, that opportunities are sought for residents to develop personally, such as work placements at local farm and hairdressers. Other activities include going to the gym, college and resource centres. On the day of the inspection two residents had entertained visitors whilst someone else went out to a country and western dance at the local church. An occupational therapist visits one of the residents regarding developing cookery skills. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 11 One resident was pleased to speak to the inspectors about the contact they have with their family, and recent and future family events. Residents are supported by staff to maintain contact with families where sometimes there have been difficulties in the past. Residents are also supported in going on holiday. One resident told the inspectors they were going abroad for a week, supported by staff. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 The home has a satisfactory medication system in place and a suggestion is made relating to ensuring that residents self-medicating whilst on social leave are risk assessed. EVIDENCE: The medication of two residents was checked and was found to tally with the records held. Appropriate codes are used, however risk assessments should be carried out for those residents self-medicating whilst on social leave. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: These standards were not assessed during this inspection. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28,30 Shared spaces complement and supplement the individual rooms of residents. The home is clean and hygienic. EVIDENCE: Communal rooms are available for residents to use. There are two lounges – one where residents can smoke and the other which is non-smoking. New furniture has been purchased for the non-smoking lounge. A new fire and fireplace have also been purchased and are to be fitted in the near future. The home was clean and hygienic on the day of the visit. It was reported that the television reception issue raised during the last inspection has been resolved, with the purchase of digiboxes for both communal rooms and for those residents who wanted this. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 35 Staff do receive training, however care needs to be taken that all staff receive core training suitable to meet the needs of the resident group. EVIDENCE: Training records were seen which identified that staff are receiving training on a regular basis. This training includes medicine administration, emergency aid, Health and Safety, Adult Protection and Food Hygiene. Five members of staff have completed the NVQ 3 award and a further four are working towards the award. A training plan is in place, however care needs to be taken to ensure all staff receive core training. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 16 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,42 Residents do benefit from a well run home. The health, safety and welfare of residents is promoted and protected. EVIDENCE: Fire drills are recorded as being carried out in November and December 2005; the records indicate that twelve members of staff participated. Following a recommendation in the last inspection report, a new fridge and fridge thermometer have been purchased. The manager of the home is working towards the NVQ level 4 award. This should be completed by June 2006. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 X 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 X 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 2 X 2 X X X X 3 X Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 18 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. 2. 3. Refer to Standard YA20 YA35 YA37 Good Practice Recommendations It is recommended that where residents self medicate whilst on social leave, that a risk assessment be completed. All staff should receive core training. The manager should continue working towards her NVQ level 4 award, to ensure that it is achieved by the end of June 2006. Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Brighouse Area Office 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. Extracts may not be used or reproduced without the express permission of CSCI Lees Hall Road DS0000026347.V282472.R01.S.doc Version 5.1 Page 20 - 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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