Inspection on 11/01/06 for Lindley Cottage

This inspection was carried out on 11th January 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 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 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lindley Cottage 13/06/07

Lindley Cottage 26/06/06

Lindley Cottage 13/09/05

Lindley Cottage 05/01/05

Lindley Cottage 12/08/04

Similar services:

Larch Avenue

Alderson Road 12

Cranworth Close Registered Care Home

The Cornerstone

John Street Nursing Home

Pennine Camphill

Whitwood House

Whitwood Hall

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

CARE HOME ADULTS 18-65 Lindley Cottage 6 Lidgett Street Lindley Huddersfield West Yorkshire HD3 3JB Lead Inspector Alison McCabe Unannounced Inspection 11th & 16 January 2006 11:00 th Lindley Cottage DS0000001117.V271211.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 Lindley Cottage DS0000001117.V271211.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. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lindley Cottage Address 6 Lidgett Street Lindley Huddersfield West Yorkshire HD3 3JB 01484 645169 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 Miss Helen Sykes Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th September 2005 Brief Description of the Service: Lindley Cottage offers nursing care and accommodation for five adults with learning disabilities. St Anne’s Community Services operate the home. Lindley Cottage is a former family residence backing onto the Lindley recreation ground. It is located within Lindley village close to local amenities. There is a large garden to the rear of the property for service users’ use. There is limited parking to the front of the building. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was conducted by one inspector, was unannounced and took place over two days. As part of the inspection a tour of the premises was undertaken and discussion with staff and managers, observation of care practice and examination of records took place. Due to the nature of the service users’ learning disabilities, the inspector was unable to receive feedback about how they experience life at the home. Since the last inspection a temporary acting manager has taken over the management of the home. It is positive that a number of improvements have been made since the last inspection, including some requirements having been addressed. Service users appeared to be relaxed and looked well cared for, and staff presented as positive and motivated. There are still a number of areas that require attention in order to improve the service, however the acting manager has expressed her commitment to addressing these. What the service does well: What has improved since the last inspection? The frequency and range of activities offered to service users both inside and out of the home has increased since the last inspection. The number of restrictions placed upon service users has reduced. Agency staff are used less often than at the last inspection. Lindley Cottage DS0000001117.V271211.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. Lindley Cottage DS0000001117.V271211.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 Lindley Cottage DS0000001117.V271211.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: Not assessed on this occasion. Lindley Cottage DS0000001117.V271211.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 Individual care plans and risk assessments do not address all service users’ needs although this is in the process of being addressed. Service users are supported to make choices. EVIDENCE: Since the last inspection, some progress has been made in reviewing individual service users’ plans and risk assessments, although the acting manager acknowledged that this was still in the process of being completed. On the second day of inspection, all qualified staff were on a meeting day to discuss behavioural management guidelines and individual care plans and risk assessments for two service users in particular. On the first day of inspection, two individual care plans were examined. It was unclear from the records, due to some not being signed or dated and the layout of the file, what was historical information and what was current. Some of this had been addressed by the second day of inspection, and the acting manager had developed behavioural management plans and reviewed risk assessments for one service user to be discussed at the qualified staff meeting. Through discussion with the deputy manager, it was apparent that agreed behavioural management strategies were not always implemented Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 10 consistently. The acting manager explained that this would be discussed at the meeting and strategies reviewed and agreed. Since the last inspection, seclusion has not been implemented at this home, although it is written as an intervention in two service users’ records. The inspector was unable to find evidence of multi-disciplinary agreement for this, although is aware that meetings have been held to discuss physical intervention and seclusion. It should be made clear who has been consulted or involved in any decision to use physical intervention and seclusion. Records of physical intervention contained the required information and good details of any incident and how it had been managed. Since the last inspection, the number of restrictions placed upon service users has been reduced. For example, the kitchen, dining room and service users’ wardrobes are now accessible with appropriate support. Staff reported that this had had a positive impact upon service users as they now have more freedom within their home. Service users were observed to help themselves to fruit and snacks from the kitchen, which is positive. Discussion took place with the acting manager and deputy manager about the rationale for keeping the bathroom on the first floor locked. The acting manager explained that this is to prevent a service user from flooding the bathroom, however agreed that alternative strategies would be considered. Any such restrictions need to be based on assessed risks and kept under review so that less restrictive measures can be introduced at the earliest opportunity. Staff described how service users are encouraged to make choices, for example, what clothes to wear, what to eat/drink, what activity they would like to do. Some examples of service users being offered and making choices were observed during the inspection. Service users are supported to take risks as part of an independent lifestyle, for example, going food shopping with staff, accessing the kitchen and attending community-based activities. Some of the risk assessments that were examined contained clear guidance to staff about the nature of the risks and agreed steps to minimize the risks. Some risk assessments need to be clearer; this was discussed with the acting manager at the time. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 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 the following standard(s): 12,13,15,16,17 Staff are working to increase the range and frequency of activities offered to service users both in the home and in the community. Staff offer good support to service users to enable them to maintain contact with their relatives. Service users are offered a nutritionally balanced and varied diet. EVIDENCE: Staff reported that opportunities for service users to access activities outside the home have increased since the last inspection. Of the five service users living at Lindley Cottage, one attends day services two days per week, and one attends college one evening per week. Staff said that service users have the opportunity to go out approximately twice a week. The acting manager is in the process of introducing activity timetables to ensure that service users are engaged in meaningful activities. Due to the level of staff support required to support some service users in the community, opportunities have to be offered on a rotational basis. The acting manager and staff explained that some service users require one to one or two to one staffing ratios outside of the home, and this reduces the opportunities that are available as there are only Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 12 three staff members on duty at any one time. Where possible, staff support those service users requiring two to one or one to one staffing to go out on days that other service users are attending day services or college so that service users remaining at the home have the highest possible staffing ratio. Staff reported that service users had all received activities/games etc for Christmas to increase the range of activities available within the home. A service user who enjoys wine had been given a wine making kit and staff have arranged to support her in making this. During the inspection, staff were observed to encourage service users to engage in activities some of the time, for example, putting washing away and doing a puzzle. The deputy manager reported that staff and keyworkers were still in the process of trying to identify activities that service users would enjoy and benefit from. Through examination of records and discussion with staff, there is evidence that service users are supported to maintain links with their families. A Christmas party had been held at the home and relatives of service users were invited. A service user had recently had a 40th birthday party at a local venue that friends and family attended. Staff reported that the relatives of a service user had commented on how settled and happy their relative had appeared to be at the birthday party. As mentioned previously in this report, restrictions placed upon service users noted at the previous inspection have been reduced significantly. Service users now have unrestricted access to most parts of the home, with the exception of the first floor bathroom and the office and laundry areas. The acting manager said that the practice of keeping the bathroom locked would be reviewed considering the identified risks. Viewing holes in some parts of the home have been filled in order to protect service users’ privacy and dignity; there are two remaining in the service users’ bedrooms who are secluded as a method of managing challenging behaviour. This must be kept under regular review in conjunction with reviews of behaviour management strategies. None of the service users living at Lindley cottage have a key to their bedrooms due to the level of learning disability, although one service user indicates to staff when he wants his bedroom door to be kept locked. Service users were observed to choose when to spend time alone or in the company of others. Menus were examined and demonstrate that a varied diet is offered to service users. Staff usually record if fruit and vegetables have been offered, although this needs to be recorded consistently. It was positive to note in records that weight gain and the negative impact of this for a service user had been noted and appropriate steps taken to address this. Staff reported that service users are offered a choice of meals and that photographs of foods were being collected to enable all service users to make positive choices. There was sufficient food supplies and opened foods were labelled appropriately in the Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 13 fridge. Staff reported that service users that enjoy and benefit from participating in the food shopping are supported by staff to do this on a weekly basis. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 14 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): 18,19,20 There is insufficient information available to ensure that service users always receive personal support in the way they prefer or require. Service users are supported to have their healthcare needs met. Medicine management is generally good although needs to improve in the area of prn medications. EVIDENCE: Staff were observed to offer personal support to service users in a sensitive and discreet manner. Care plans for two service users were examined as part of this inspection. Records examined did not clearly set out service users’ preferred routines, likes or dislikes, therefore additional information needs to be included within individual care plans about how service users prefer to be supported with their personal care. This is particularly important for service users who cannot easily communicate their needs. The deputy manager reported that the use of agency staff to cover shifts has reduced since the last inspection, although on average about two shifts per week are still covered using agency staff. Although, wherever possible, the same agency staff are used, there are occasions when this is not possible. It is important that all staff supporting service users with their personal care are clear about individuals’ preferred routines. Since the last inspection, service Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 15 users have been provided with toilet paper, soap and towels in the ground floor toilet and this is positive. The deputy manager reported that this has not caused any difficulties to service users. The first floor toilet has been fitted with a toilet roll dispenser, however the acting manager reported that this was broken therefore no toilet paper is available. As the bathroom is kept locked, service users do not have access to a wash hand basin without staff support. It is a requirement of the inspection that the toilet roll dispenser be repaired or replaced. There was evidence in records examined that service users are supported to attend healthcare appointments, for example, GP, dentist, psychiatrist. An ‘OK health check’ is completed in respect of each service user in order to identify healthcare needs. Medication checked tallied with the medication administration records. ‘As required’ (prn), guidelines for some service users were clear and gave staff explicit instructions about when to administer prn medication. A description of the reasons why a service user was prescribed her medication was included in the records and this is good practice. The possibility of extending this practice in respect of all service users was discussed with the deputy manager. Prn guidelines in respect of a service user given medication to control challenging behaviour need to be clearer and should be dated and signed so that it is apparent when they were developed. There was evidence that staff had not consistently followed guidelines for administering prn medication to a service user. This was discussed with the acting manager who had taken steps to address this by the time of the second day of inspection. Service users do not have individually prescribed Paracetamol, and staff and service users use the stock of Paracetamol. It is recommended that only service user medication be stored, administered and recorded at the home and that service users have their own supply of Paracetamol where necessary. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 16 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): 22,23 A satisfactory complaints procedure is available at the home. There is not sufficient information in all care plans and behaviour management plans to protect service users from potential harm or abuse. EVIDENCE: A satisfactory complaints procedure is in place. This is also available in symbol format. The acting manager reported that no complaints had been received at the home since the last inspection. A satisfactory adult protection procedure, including whistle blowing, is in place in addition to the Kirklees Vulnerable Adult procedures. Physical intervention and seclusion are used at this home to manage the behaviour of two service users although, since the last inspection, seclusion has not been used and the frequency of physical intervention has reduced. The acting manager explained that she has been working with the staff team to improve understanding of aggression displayed by service users and to implement de-escalation techniques. Staff spoken to seemed to have a better understanding of some behaviour that is displayed and said that the atmosphere at the home had improved recently. There was evidence that staff had identified a number of triggers to a service user’s behaviour and suggested ways to de-escalate potential and actual incidents of aggression and distress. This information was being discussed at the qualified staff meeting being held on the day of inspection and was then to be formalised as part of a general behaviour management plan. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 17 Behaviour management plans for one service user did not contain sufficient clear detail. The acting manager said she was aware of this and that this too would be discussed and addressed at the qualified staff meeting. The inspector did not see any evidence of multi-disciplinary agreement in respect of physical intervention and seclusion being used with service users and this must be available. As previously mentioned, records relating to incidents of physical intervention have improved since the last inspection and were found to contain the required detail. The acting manager reported that staff had received a half-day update on physical intervention from the service manager since the last inspection. St Anne’s are in the process of having senior staff within the organisation trained to become physical intervention trainers accredited by the British Institute of Learning Disabilities and this is a positive step. Following the last inspection, the service manager reported that he had arranged for a specialist consultant to work with the staff team in respect of managing and understanding individual service users’ behaviours. The acting manager reported that this has not been achieved as yet due to the existing work commitments of the specialist consultant. The inspector was unable to verify which staff had received the appropriate training in physical intervention, as staff training records were incomplete. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 18 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): 24,30 Service users live in a comfortable environment. The home is mostly clean but an unpleasant odour is present in some areas. EVIDENCE: All parts of the home were seen as part of this inspection. Most areas of the home were clean and free from unpleasant odour. The deputy manager reported that they were still waiting for a date for laminate flooring to be fitted in a service user’s bedroom. An unpleasant odour was present in the downstairs toilet and sitting room. The deputy manager reported that staff had made many attempts to clean the seating and carpet in the sitting room but had been unable to eliminate the odour. This needs to be addressed. Most service user bedrooms were personalised and furnished comfortably. Locks on wardrobes have been removed giving service users’ access to their personal belongings. Staff reported that this had had no adverse effects on service users. The deputy manager explained that the bedrooms with few personal items were kept in such a way so as to create a low arousal environment for those service users for whom this is important. Fibre optic lights have been used to decorate the sitting room. Staff reported that service Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 19 users seem to enjoy these and that it creates a relaxing atmosphere, particularly in the evenings. Since the last inspection, the stable door to the kitchen has been replaced with a regular door that is kept unlocked. All communal areas of the home are now accessible to service users with the exception of the first floor bathroom. If this practice is to remain, there must be evidence that it has been agreed, is in the best interests of the service users, and is based on identified risks. It must be kept under regular review so that restrictions placed upon service users are reduced or removed at the earliest opportunity. View holes are in place in two service user bedroom doors to enable staff to observe service users if they have been locked in their bedrooms as a way of managing behavioural incidents. This raises concerns about the protection of service users’ privacy and dignity at times when seclusion is not being used. The potential risks to those service users needs to be recorded and kept under regular review. The laundry is situated in the garage and the washing machine has a sluice cycle. Infection control policies and procedures are in place and suitable arrangements have been made for the disposal of clinical waste. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 20 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): 32,33,34,35 A committed staff team supports service users although further training is necessary. Service users are supported by a consistent staff team for most of the time. EVIDENCE: At the previous inspection, the staff team and service users had been going through a difficult period of adjustment following the admission of a service user in March 2005. Staff were often working in a reactive way in trying to manage challenging behaviours that were presented. The acting manager, deputy manager and staff reported that the home was much more settled and that there had been more focus on proactive approaches to avoid serious behavioural issues. Service users were observed to be comfortable in the company of staff during the inspection. Staff presented as committed to providing a good service and commented that there had been positive changes in the last few months. For example, incidents of challenging behaviours displayed by some service users had reduced; the frequency of agency staff being used to cover shifts had reduced. Staff training records were examined in order to establish whether staff have received training relevant to the needs of the service users. Records had not been maintained therefore it was not possible to get an overview of training Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 21 that had been provided. The acting manager explained that she was aware that these records were incomplete however had not had the opportunity to address this. She also informed the inspector that she had arranged for all staff to attend mandatory training during February, March and April 2006 as they had not attended training during the previous year. This is to include movement and handling, first aid, health and safety, adult protection and food hygiene. There was evidence that this had been booked. A requirement was made at the previous inspection that staff be provided with accredited training in physical intervention and behaviour management. The acting manager reported that staff had received a half-day refresher session in physical intervention. The training currently provided to St Anne’s staff is not accredited, however as previously mentioned in this report, senior staff within the organisation are currently working towards becoming accredited trainers in physical intervention. The service manager has explained that the new course focuses much more on de-escalation and diffusion techniques. The organisation has a comprehensive training and development plan covering mandatory training and a range of other training relevant to the service provided. This is in addition to NVQ and LDAF training which is ongoing. Of five care staff, one has achieved NVQ level two, and one has almost completed NVQ level three in care. A new member of the care team is in the process of completing the LDAF induction and foundation training. It is recommended that at least 50 of all care staff have an NVQ two in care. There are currently vacancies for one full time support worker and thirty-seven additional hours per week to provide additional support for one service user. The deputy manager reported that agency staff are used approximately twice per week and bank staff employed by St Anne’s and the home’s own staff also work extra shifts in order to cover the rota. As far as possible, agency staff familiar with the home and service users are used in order to provide consistency, although this is not always possible. The deputy manager said that interviews had been arranged and that they were hoping to recruit suitable staff to fill all vacant positions. Regular staff meetings take place and minutes of these were seen. Records of three staff members were examined as part of this inspection. Recruitment records are held centrally by the organisation and were therefore not available for inspection. The provider and CSCI are in discussion regarding this matter. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 22 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): 37,39,41,42 A suitably qualified acting manager is temporarily running this home. Satisfactory quality assurance and monitoring systems are in place at this home although a system for publishing the results needs to be developed. Record keeping is satisfactory in some areas, however needs to improve in some areas. The health and safety of staff and service users could be further protected in some areas. EVIDENCE: The registered manager has taken a career break and an acting manager has been brought in to oversee the running of the home. The acting manager is a registered nurse for people with learning disabilities and has worked in a management role since May 2004; she also has the Registered Managers’ Award, NVQ level four in care and is an assessor of NVQ students. Staff gave positive feedback about how the home is being managed. It had been agreed that the acting manager would be in post for a period of six months from Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 23 October 2005. The acting manager was unsure of the management arrangements after this time. The provider must inform the CSCI of the longterm management plans for this home. Questionnaires are sent to relatives/friends of service users seeking their views about the quality of service offered although the results of the questionnaires are not published or made available to service users or other interested parties; a requirement has been made in respect of this. The home has an annual development plan that is available in the home. The manager reported that she is considering arranging regular standard setting meetings for nursing staff and support staff where the quality of the service will be monitored. Records required by regulation were not all available, up to date or complete. Reference has been made to specific records previously in the report, and a requirement has been made in respect of record keeping. Records of health and safety checks were examined. Most records were well maintained and demonstrate that required maintenance of equipment and safety checks are conducted. Records of fire safety checks and training were mostly up to date with the exception of the weekly fire alarm check. The records show that a weekly test of the alarm is not being conducted consistently and a recommendation is made in respect of this matter. In order to ensure the health and safety of service users and staff is protected, all service users must have clear and current individual service user plans, behaviour management strategies and risk assessments. This is discussed earlier in the report. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 24 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 3 23 1 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 1 STAFFING Standard No Score 31 X 32 2 33 2 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 3 X 1 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 1 3 2 X 2 X 1 X 1 2 X Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 25 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 YA6 YA18 YA23 YA41 Regulation 12(1)a,15(1), Sch 3 Requirement An up to date, comprehensive, person centred plan must be in place for all service users. This must include personal support needs, behaviour management plan including physical intervention plan, a record of any limitations agreed with the service user as to the service user’s freedom of choice, liberty of movement and power to make decisions. Detailed risk assessments must be in place for all service users. Risk assessments currently in place must be reviewed to ensure they contain sufficient detail. Service users must be supported to have their personal care needs met. Service users must have access, with support if necessary, to items required for their personal Timescale for action 15/03/06 2 YA9 YA41 13(4) 15/03/06 3 YA18 12(1)a,b,(4)a 15/02/06 Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 26 care, including toilet paper, hand soap and towels. 4 YA33 12(1)b,18(1)a The registered person must ensure that at all times suitably qualified, competent and experienced persons are working at the home in such numbers as are appropriate for the health and welfare of service users. Staff vacancies must be filled. 12(1)a,b 13(2) 15/03/06 5 YA20 6 YA39 24(2) 7 YA34YA35YA41 17(2) The registered person 28/02/06 must ensure that prn medication guidelines give clear instructions about when medication should be administered. Prn medication must be administered as per the instructions and guidance. The registered person 15/03/06 must make the results of service user/relatives surveys, in respect of quality of care provided, available to service users. A record is kept in the 15/03/06 home in respect of each person employed, which contains all the information stipulated in Schedule 4(6) of the Care Homes Regulations 2001. This includes a record of training undertaken including induction training. Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 27 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 YA6 YA23 Good Practice Recommendations Behaviour management plans currently in place should be reviewed to ensure they are current, clear and in line with current good practice guidelines. It is recommended that only service user medication be stored, administered and recorded at the home and that service users have their own supply of Paracetamol where necessary. The registered person should continue working towards 50 of all care staff achieving NVQ level 2 or above. The provider should notify the CSCI of the proposed future management arrangements at the home. The fire alarm should be tested weekly and a record kept. 2 YA20 3 4 5 YA32 YA37 YA42 Lindley Cottage DS0000001117.V271211.R01.S.doc Version 5.1 Page 28 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. 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