Inspection on 13/06/07 for Lindley Cottage

This inspection was carried out on 13th June 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 found no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lindley Cottage 26/06/06

Lindley Cottage 11/01/06

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 19/06/2009.

CARE HOME ADULTS 18-65 Lindley Cottage 6 Lidgett Street Lindley Huddersfield West Yorkshire HD3 3JB Lead Inspector Key Unannounced Inspection 13th June 2007 11:00 Lindley Cottage DS0000001117.V323809.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 Lindley Cottage DS0000001117.V323809.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. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 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) www.st-annes.org.uk St Anne`s Community Services Mrs Dawn Moran Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 26th June 2006 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 that is accessible to people living at the home. There is limited parking to the front of the building and level access to the ground floor of the building. The fees for this service are £407.94 per week; this does not include the nursing component, which is paid for directly by health. Lindley Cottage DS0000001117.V323809.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 key inspection, a visit was made unannounced to Lindley Cottage by one inspector between the hours of 11.00am and 6.00pm. In addition to the visit, information used to inform the inspection includes: information submitted to CSCI about the service, the people who live there and the staff who work there, completed surveys from health professionals and relatives/carers/advocates of people living at the home giving views about the quality of the service. All indications on the completed surveys are positive with all expressing overall satisfaction with the service received or delivered at the home. Completed surveys were received from one health professional, and three relatives/carers/advocates of people who live at the home. Some of the comments received include: “They understand his needs and he is kept well dressed and clean. He seems a lot happier person since his stay at Lindley Cottage”. “Looks after residents in a caring and compassionate manner and ensures that they have a good quality of life”. “Homely atmosphere. Since there are just five residents in Lindley Cottage, it is easier to create an atmosphere resembling a good family home”. Further comments are included in the main body of this report. As part of the visit the inspector had the opportunity to talk to the registered manager, staff on duty and three of the people that live at the home. Time was spent observing care practice and interaction between staff and people living at the home. All communal areas and bedrooms were seen and a sample of records was examined. These include: Individual care plans, information about potential risks and agreed steps that should be taken to minimize these risks, health action plans and daily records, accident and incident records, staff training records, staff rotas, recruitment records and records of safety checks and maintenance. Medication and records relating to medication were examined. The inspector would like to thank the people living at Lindley Cottage and staff for their cooperation and hospitality during the visit. What the service does well: Before people move into the home, their needs are properly assessed. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 6 People have an individual care plan that is reviewed regularly so that staff know how to meet peoples needs. People living at the home are offered regular opportunities to go out with support from staff. Policies and procedures are in place to protect people living at the home from abuse. A clear complaints procedure is in place. People live in a clean, comfortable environment. Staff offer good support to individuals to enable them to maintain contact with their families and friends. Staff support to individuals to have their health and personal care needs met. People living at the home are supported to make some choices. Good food is provided at this home. A committed staff team supports people living at the home. Staff receive relevant training on a regular basis. Systems are in place to seek the views of individuals’ families about the service they receive. The manager is qualified and experienced. People living at the home have positive relationships with staff. What has improved since the last inspection? What they could do better: Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 7 Further development of some risk assessments and behaviour management plans is necessary in order to properly support and protect people living at the home. Beds and mattresses need to be replaced promptly when it is found that they are damaged or worn. Physical intervention plans need to be implemented as agreed, and multidisciplinary agreement (for example agreement with people’s doctors, psychologists, community nurses and social workers) of the plans needs to be evidenced. Essential maintenance work needs to be carried out in a timely fashion so that people living at the home can have access to the facilities provided. In order to protect the privacy of people living at the home, the lock on the toilet door should be repaired and viewing holes no longer required should be removed. More care needs to be taken to ensure that all staff have had the necessary criminal records bureau checks before working with vulnerable people. 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. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 8 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.V323809.R01.S.doc Version 5.2 Page 9 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Peoples’ needs are assessed before they move into the home so that staff are aware of individuals’ needs and aspirations. EVIDENCE: Records relating to three people using the service were examined, and all contained evidence their needs had been assessed prior to them moving into the home. Information received prior to the visit indicates that there have been no new admissions to the home since the last inspection. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 10 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People’s needs and identified risks are generally reflected in their individual plan and people are supported to take some reasonable risks and make some choices, however clearer information is required in some areas about how to meet individuals specific needs. EVIDENCE: Three individual plans were examined. In general there was clear information about how peoples needs should be met. A person centred planning approach is used at this home and there was evidence that regular reviews take place. A member of staff confirmed this and said that the named nurse reviews the care plan monthly to monitor progress and check that individuals assessed needs have been met. She reported that this was a useful exercise. Where possible, individuals’ families are invited to be involved in the annual review. Goals are agreed for each person at their person centred planning meeting and there was evidence that for some people these goals were being achieved. It was noted however, that not all agreed goals are being achieved in a timely fashion, for example, it was identified in December that an individual required Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 11 a new mattress, however this has still not been purchased. The manager reported that this was in the process of being addressed. Behaviour management plans are in place for some of the people living at the home. Some were clear and gave good instructions to staff about how to manage incidents of challenging behaviour. There was evidence on the day of inspection that staff managed a behavioural incident well and in line with the agreed behaviour management plan. The behaviour management plans focused on positive approaches, with the exception of one plan that needs to be reviewed to reflect the positive approaches now being used at the home. This was discussed with the manager at the time. Physical intervention plans are in place for two individuals. These were clear and records had been kept of incidents where physical intervention had been used. Some of these records did not demonstrate that the physical intervention plan had been followed as agreed. This was discussed with the manager who explained that there were alternative methods that had been agreed in team meetings. The manager was advised to ensure that this was made clear in the written plans. Records also suggested that some staff resort to physical intervention much more quickly than others, although the records did not suggest that this was based upon intensity of behaviours being displayed. The manager is aware of this and is in discussion with the staff team on a regular basis to try to establish consistency across the team. Staff confirmed that physical intervention, including the practicing of holds and equipment was discussed at the staff meetings. There was no written evidence of multi-disciplinary agreement with regards to physical intervention and this needs to be addressed. Seclusion is used with one person living at Lindley Cottage and there was evidence that this method of managing challenging behaviour is kept under review. The use of seclusion for a second person living at the home has been stopped as staff feel that alternative methods of managing the individual’s behaviour are effective. The seclusion plan for this individual has therefore been removed. The viewing hole in this individual’s bedroom is however still in place, and this should be filled in if it is no longer necessary in order to protect the privacy of the individual. People living at the home are supported to make some choices and decisions, although due to the nature of peoples’ learning disabilities this is often quite limited. Staff gave examples of how people are supported to make choices about what food or drinks they would like. Those that were in the house on the day of inspection were observed to help themselves to fruit or indicate when they wanted drinks or snacks. Staff seemed to be aware of how individuals’ communicated their choices. A staff member reported that she had decided on floor covering for an individual’s bedroom as it is due to be redecorated. Care should be taken to involve individuals as much as possible in decisions about their home. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 12 Identified risks to individuals have been appropriately assessed and in general clear guidance is available about how staff should minimize these risks whilst still supporting people to lead as independent a lifestyle as possible. It was noted in the records of one person that further information was necessary about how staff should intervene with an individual and make a particular situation as safe as possible. The risk assessment in place suggested that physical intervention would be necessary, however no further information was available about how this should be implemented, and no agreed plan was in place. Although the manager reported that the risky behaviour occurred infrequently, it is still essential that staff have clear guidance about how to respond in the event that physical intervention is required. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 13 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): 12,13,15,16,17 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home generally have good opportunities to participate in activities both in and out of the home, are offered good support to stay in touch with their families, have their rights respected and are offered a reasonably balanced diet. EVIDENCE: Records examined showed that some people living at the home have access to day service provision. The manager and staff confirmed this. For those that don’t have this provision, staff at the home are responsible for providing opportunities to people to participate in community based activities and occupation in the home. The manager reported that at the time of the visit, two staff were supporting two people from the home on holiday, and this had impacted on how often the three remaining individuals had been able to go out during this period. During the inspection it was noted that people spent a lot of time wandering around the house with little to do, although some staff were observed to support individuals with making drinks. One individual made Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 14 repeated requests to go out, however this was not possible as staff were supporting one of the other individuals in the community. The manager reported that opportunities are usually much better and that upon the return of the staff from holiday, the usual level of activity would resume. The manager needs to ensure that enough staff are on duty at all times to ensure that people living at the home can maintain their usual levels of activity regardless of whether some staff are on holiday with other individuals. Records examined indicate that people are continuing to receive a reasonable number of opportunities to go out of the home and that progress in this area has been maintained since the last inspection. There was evidence in the records of people being supported to maintain contact with their families. This included families visiting the home or people being supported to visit their families. Review records indicate that families are invited to participate in person centred planning meetings and are involved in this process. Three surveys were completed by relatives/carers/advocates of people living at the home. All three indicated that the home helps their relative to keep in touch with them. There are some restrictions placed upon people living at the home in order to protect them from harm, and these are recorded and agreed within individuals’ records. For example, although the kitchen continues to be kept open and accessible, a lock is fitted to the fridge door to prevent individuals from eating uncooked foods. People do however have access to other foods that are accessible and can access the fridge with staff support. The bathroom on the first floor is still being kept locked. At the last inspection conducted in June 2006, the manager had explained that refurbishment of the bathroom was imminent and that all hazards to peoples’ safety had been removed. It was planned that the bathroom would be made accessible to people following completion of the refurbishment. This is still not complete and the manager explained that this was due to the workload of the maintenance department. The restricted access to the bathroom should be resolved as soon as possible. Staff were observed to respect individuals privacy by knocking on bathroom or bedroom doors before entering. Records of food were examined and suggest that a reasonably healthy and varied diet is offered. Staff on duty explained that people living at the home are encouraged to make choices about what breakfast and lunch they would like, but that the evening meal is generally chosen by the staff on duty. Staff said that they had attempted to use pictures of meals to support people to make choices but with little success. Staff reported that individuals at the home sometimes participate in food shopping with staff depending on what else they have planned and whether or not they want to go. Food was stored appropriately and fresh fruit and vegetables were available. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 15 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 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People living at the home receive personal support in the way they prefer or require, are supported to have their healthcare needs met, and medicine management is good. EVIDENCE: All the people living at the home require some support with their personal care. Individual support plans contained comprehensive, detailed information about how individuals prefer to be supported so that all staff use a consistent approach. The manager described how staff are continuing in their attempts to engage physically with an individual in a positive manner using massage, as it has been recognised that there is potential for the only physical contact to be when physical intervention is used. It is positive that the manager continues to implement a pro-active approach in this area. All people living at the home have a keyworker and a named nurse, and those staff spoken to were clear about this role and were able to describe work they had been doing in keeping care plans up to date and supporting individuals with their agreed goals. Staff were observed to offer personal care in a discreet and sensitive manner. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 16 There was evidence in records examined that people living at the home have their healthcare needs met. An ‘OK health check’ is completed annually to identify any healthcare matters that need addressing. Those examined were complete and detailed. There was evidence in the records, and through discussion with staff, that people are supported to attend healthcare appointments where necessary. A survey completed as part of this inspection by a health professional indicated that the home communicates clearly with them and works in partnership, enables individuals to be seen in private, and specialist advice is incorporated into the care plan. The health professional has not received any complaints about the home. Medication and medication records were examined. All medication could be reconciled with the records kept, and medicine management was found to be good. Clear instructions about when emergency medication should be given and what the desired effect is were in place. Information also included individuals preferred method of taking their medication, and this is good practice. Medication is stored securely at this home. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 17 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. Clear complaints and protection procedures are in place, and some people using the service have clear behaviour management plans, however in order to ensure that all people living at the home are protected from potential harm, further development in some areas is necessary and consistent implementation of agreed plans needs to be achieved. EVIDENCE: The home has a clear complaints procedure that is available in symbol format in each individual’s file. Information received prior to the visit indicated that no complaints have been received about this service in the last twelve months and the manager confirmed this. Three surveys completed by relatives of people living at the home all indicated that they knew how to make a complaint about the care being provided, and two said that the care home always responded appropriately if concerns were raised, and one said that the care home usually responded appropriately. A satisfactory adult protection procedure, including whistle blowing, is in place in addition to the Kirklees Vulnerable Adult procedures. Staff spoken to knew where to find the procedures if needed and were clear about their responsibilities in this area. Concerns have been raised previously at this home about the management of challenging behaviour. Records examined showed that for some people living at the home there are clear and detailed behaviour management plans, including physical intervention plans, so that staff adopt a consistent approach Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 18 when managing behavioural incidents. Staff spoken to said that these were working well and that they are discussed regularly at team meetings. On the day of the visit, staff implemented the agreed plan successfully. As previously mentioned, records of physical intervention suggested that not all staff are following the agreed written plan and this needs to be addressed either in terms of staffs practice or reviewing the plan. No evidence of multi-disciplinary agreement could be found in respect of physical intervention, and in order to improve practice in this area, this should be sought. As discussed under standards 6-10, further information and review is necessary in relation to some individual plans and risk assessments. The manager reported that all staff were up to date with training including adult protection and physical intervention training. Those staff spoken to confirmed this, and the training records sampled also confirmed this. The manager reported that she had been offered the opportunity by St Anne’s to attend additional training in behaviour management and would be starting the course in September 2007. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 19 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People live in a generally clean and comfortable home although a more timely response to maintenance matters would improve the environment for the people living at Lindley Cottage. EVIDENCE: All parts of the home were seen during this visit, including all communal areas, and each person’s bedroom. Most parts of the house were clean and free from unpleasant odour. Since the last visit, new furniture has been purchased for the lounge, the lounge radiator cover replaced and the hallway has been redecorated and re-carpeted. The manager reported that a number of bedrooms were due to be re-decorated and that keyworkers had started supporting individuals with choosing colours etc. It was noted in one bedroom that the bed base was broken causing the mattress to slope at one end. The manager reported that she was aware of this, however at the time of the visit no arrangements had been made to replace the bed base. A requirement has been made in respect of this. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 20 The manager reported that the maintenance department is having ongoing difficulties in dealing with matters arising in a timely way. Plans to move the office/sleep in room into the garage to provide a quiet lounge are no further forward than at the last inspection. The first floor bathroom remains locked and inaccessible to people living at the home without supervision from staff, as maintenance work has not been completed, although the manager was hopeful that this was imminent. The bathroom is the only area with hand washing facilities on the first floor, as the toilet situated next door to the bathroom does not have a sink. Vanity units have been fitted in the first floor bathroom and ground floor toilet, however the manager reported that they are waiting for locks to be fitted so that cleaning materials can be stored safely. There is no blind or curtain in the bathroom, however the manager reported that this is on the list of jobs waiting to be done. The lock on the first floor toilet door is broken and the manager reported it had been for some time. This must be repaired in order to protect the privacy of the people living at the home. As discussed previously in this report, view holes are fitted in two individuals bedroom doors so that staff can observe during periods of seclusion. As seclusion is no longer required for one individual, the necessity for the view hole is questionable and should be reviewed. 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.V323809.R01.S.doc Version 5.2 Page 21 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A committed, consistent and trained staff team supports people living at this home, however in order to ensure the protection of people living at the home, the provider must ensure that all necessary checks on staff are undertaken when required. EVIDENCE: Staff on duty at the time of inspection appeared to have positive relationships with the people living at the home. Staff spoken to had a good understanding of individuals needs and presented as committed to providing a good service. Three relatives of people living at the home returned surveys and all said that in their opinion care staff usually have the right skills and experience to look after people properly. One commented, “ There are bound to be occasions when new or temporary workers who are not as experienced as the permanent staff will fall short of the standard that experienced staff will give”. Of six care staff working at the home, two have completed NVQ level two or above, and two are currently working towards this qualification. All new staff complete the Learning Disability Award (LDAF) induction and foundation training, and evidence of this was seen in staff training records. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 22 Staff recruitment records are held centrally, however the organisation have a system whereby a record is kept in the home confirming dates that the required pre-employment checks have been received. These were sampled during the visit and in general demonstrated that good recruitment practice is implemented as required by the regulations. However, it was found that a member of staff was working in the home without a current Criminal Records Bureau (CRB) check and that this had been identified by the organisation in June 2006. It is concerning that this had not been followed up sooner, although the manager said that the form had been sent to the CRB recently, and confirmed the day after the visit by telephone that a clear check had just been received by the staff member. The manager must ensure that staff do not work with vulnerable adults without CRB clearance including a check against the Protection of Vulnerable Adults (POVA) register. Though discussion with staff, the manager and examination of staff training records, it is evident that staff receive regular relevant training. There is an annual training plan in place, and since the last inspection staff have attended refresher training in movement and handling, fire safety adult protection and health and safety. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 23 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. A suitably qualified and experienced manager runs the home and the quality of the service provided is monitored, however whilst people’s health and safety is protected in most areas, some improvements are necessary in this area. EVIDENCE: Since the last inspection, the manager has been registered by the Commission for Social Care Inspection (CSCI). The 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. All staff spoken to gave positive feedback about the management style and described the manager as approachable and professional in her approach. The registered manager reported that she has attended relevant training in order to maintain and develop skills and knowledge, and evidence of this was seen in training records. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 24 The manager reported that annual quality assurance surveys are sent to families of the people living at Lindley Cottage. Due to the level of individuals’ learning disabilities, it would not be possible to ascertain their views using surveys. Completed surveys are returned centrally, and the manager explained that general feedback is given about the results, rather than feedback specific to individual homes. In addition to this, monthly visits are conducted in line with the Care Homes Regulations, and a report of the visit is compiled. The nominated person for these visits is a registered manager from another St Anne’s home. A copy of the report was submitted to CSCI following the inspection visit, and showed that some attempt had been made to ascertain the views of people living and working at the home. The monthly provider visits are currently pre-arranged, however should be unannounced in line with the Care Homes Regulations. This was discussed with the registered manager following the inspection visit. The home has an annual development plan, which is available in the home. Progress with this is monitored monthly by the manager and senior managers within the organisation. As part of this inspection three relatives and one healthcare professional completed a survey and all indicated that they are satisfied with the care provided at Lindley Cottage. Information gathered prior to the visit indicates that maintenance of equipment and necessary checks have been carried out at the required intervals with the exception of portable appliance testing. The manger confirmed that this was due in January 2007, however due to the workload of the maintenance department, this has not been completed. In order to ensure the safety of people living and working at Lindley Cottage, the required checks should be carried out when they are due. It was noted whilst touring the premises, that although there are lockable storage areas for substances that may be hazardous to people living at the home e.g. cleaning fluids, cupboards had not been locked. This was discussed with staff at the time and the cupboards were locked immediately. Through discussion with the manager, staff and examination of accident and incident reports, it was noted that a number of incidents that should have been reported to the CSCI under Regulation 37 of the Care Homes Regulations 2001 had not been. These included incidents of physical intervention. As mentioned previously in this report, further development of some risk assessments and behaviour management plans is necessary in order to protect the people living and working at the home. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 25 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 2 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 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 2 X Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 26 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. 1. Standard YA6 Regulation Requirement Timescale for action 15/07/07 12(1)a, 13(7) Physical intervention plans 15(1), Sch 3 must be implemented as agreed, and physical intervention must only be used when it is the only practicable means of securing the welfare of the individual and there are exceptional circumstances. There must be clear evidence of those that have been consulted and agreed to the use of physical intervention as part of an individuals care plan. 2. 3. YA24 YA24 16(2)c 23(2) 4. YA42 23(2) The damaged bed in the bedroom identified at the visit must be replaced. Maintenance work to the bathroom must be completed so that people living at the home have free access to this area. The lock on the first floor toilet door must be repaired to protect individuals’ privacy. Equipment provided at the DS0000001117.V323809.R01.S.doc 15/07/07 31/07/07 31/07/07 Page 27 Lindley Cottage Version 5.2 5. YA42 37 home must be maintained at the required intervals in order to protect the health and safety of people living at working at the home. The Commission for Social Care Inspection must be notified without delay of the occurrence of any of the events detailed under Regulation 37 of the Care Homes Regulations 2001. This includes occurrences where physical intervention or seclusion has been used. 31/07/07 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 YA24 Good Practice Recommendations In order to protect an individual’s privacy, consideration should be given to blocking the viewing hole in the bedroom door as it is no longer required. Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 28 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 Lindley Cottage DS0000001117.V323809.R01.S.doc Version 5.2 Page 29 - 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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