Inspection on 26/06/06 for Lindley Cottage

This inspection was carried out on 26th June 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 7 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 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 09/07/2008.

CARE HOME ADULTS 18-65 Lindley Cottage 6 Lidgett Street Lindley Huddersfield West Yorkshire HD3 3JB Lead Inspector Alison McCabe Key Unannounced Inspection 26th June 2006 12:50p Lindley Cottage DS0000001117.V296158.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.V296158.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.V296158.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) St Anne`s Community Services Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 11th January 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 for service users’ use. There is limited parking to the front of the building. The range of fees for this service are £202.30-£407.94 per week; this does not include the nursing component which is paid for directly by health. Lindley Cottage DS0000001117.V296158.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 site visit was conducted at Lindley Cottage by one inspector between the hours of 12.50pm and 7.25pm. In addition to the site visit, information used to inform the inspection includes notifications received from the home about any accidents, incidents or events that affect the well being of residents, provider monthly visit reports submitted to CSCI, the pre-inspection questionnaire submitted to CSCI prior to the site visit, completed questionnaires from health professionals and relatives of service users giving views about the quality of the service. The acting manager has explained that none of the service users were able to complete the questionnaires due to their level of learning disability. Questionnaires were also sent to five relatives - four have been returned; three professionals (social workers/GP) - one has been returned. Comments and feedback have been included within the main body of this report although the general feedback from all has been positive with all respondents expressing satisfaction with the service provided at Lindley Cottage. As part of the site visit, the inspectors had the opportunity to talk to three members of staff including a student nurse on placement, nursing care officer and support worker, and the acting manager. Communal areas of the home were seen. Records relating to service users, staff meeting minutes, complaint records and service user monies were examined. Medication and records relating to medication were examined. The inspector also had the opportunity to observe care practice and the evening meal being served. Although there remain a number of requirements and recommendations that need to be addressed, the staff and management have made significant progress in some areas since the last inspection visit. The home appears to be settling into a more stable period and staff morale was reported to be good. Service users seemed relaxed and well cared for. The inspector would like to thank the service users and staff for their cooperation and hospitality during the site visit. What the service does well: Before service users move into the home, their needs are properly assessed. Policies and procedures are in place to protect service users from abuse. A clear complaints procedure is in place. Service users live in a clean, comfortable environment. Staff offer good support to service users to enable them to maintain contact with their families and friends. Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 6 Staff support service users to have their health care needs met. Service users are supported to make choices. Good food is provided at this home. A committed staff team supports service users. Staff receive relevant training on a regular basis. Systems are in place to seek the views of service users’ families about the service they receive. Lindley Cottage is a well managed home. What has improved since the last inspection? 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.V296158.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Adequate assessments are completed prior to service users being admitted to the home. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Records of two service users were examined as part of the site visit. Both contained a completed community care assessment. Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Some individual care plans and risk assessments address service users’ needs; further development is required in some areas. Service users are supported to make choices. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Individual service user plans and records were examined in respect of two service users. Since the last inspection visit, significant progress has been made in the development of care plans, behaviour management plans and risk assessments for some service users. From the information in one care plan, it was clear what the service user’s needs were and how staff should deliver care in order to meet the identified needs. All documentation was signed and dated and it was easy to establish what information was current and what was historical. Since the last inspection visit, a new system has been introduced whereby current personal support plans, behaviour management guidance, risk assessments etc that are required on a day to day basis are filed separately in a smaller, easily accessible folder. All historical information or information not Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 10 required by staff in supporting service users on a day-to-day basis is filed separately. Clear behaviour management plans were in place for a service user whose file was examined. These were found to give clear instructions to staff about how to respond to incidents of challenging behaviour using a positive approach. Triggers to behaviours had been identified and recorded, and staff spoken to were able to describe these. The inspector saw evidence of staff implementing the agreed measures to reduce identified risks, and this is positive. Physical intervention is sometimes used at this home as a way of managing challenging behaviour. From the behavioural management plans, it was evident that this approach is used as a last resort after all other approaches have been exhausted. Staff spoken to confirmed this and were able to describe de-escalation and distraction techniques that would be implemented in the first instance. Seclusion has been used on one occasion since the last inspection. Records examined demonstrate that this was used in an emergency situation to maintain the safety of all service users and staff. The acting manager reported that seclusion has not been used since January 2006. Neither the inspector nor the acting manager was able to locate any documentation detailing who has been consulted and agreed to the use of physical intervention and seclusion. It should be made clear who has been consulted or involved in any decision to use physical intervention and seclusion and a recommendation has been made in respect of this. Records of physical intervention contained the required information. Further development of the care plan, behaviour management plan, risk and movement and handling assessments in relation to one service user is necessary. It was noted that some areas did not provide clear guidance to staff. This was discussed with the acting manager at the time of the site visit. Increased needs in the area of mobility had not been reflected in the moving and handling assessment for a service user. This was fed back to the acting manager who agreed to address this. All four questionnaires returned by relatives of service users living at Lindley Cottage stated that they were consulted about their relatives’ care and were kept informed of important matters affecting their relative; this is positive. The inspector observed several examples of service users making choices, including when to have a drink/snack. Service users have access to the kitchen and were observed being offered appropriate support to make drinks/snacks. Some of the cupboards and the fridge are fitted with locks due to identified risks of some service users eating raw food etc. The acting manager was able to clearly describe the rationale for this. A range of tabletop activities was available, and service users were seen to access these independently. Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 11 The bathroom on the first floor is kept locked and service users require staff support to access it. The acting manager reported that refurbishment of the bathroom is imminent and all potential hazards have been removed. Upon completion of the refurbishment, the acting manager reported that service users will have unlimited access to the bathroom. Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 12 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 continuing to work at increasing 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 although records of food need further detail in order to evidence and monitor this. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: 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. A service user has recently joined a local walking group and is supported by a member of staff to do this. The acting manager reported that service users are supported to go out approximately three times a week to participate in community based activities. A range of tabletop activities is available within the home and service users are supported to participate in household tasks. A member of Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 13 staff reported that there is much more emphasis on staff interacting with service users since there has been a change in management. Staff reported that service users are getting out much more than they used to. Feedback from a relative of a service user at the home confirmed this and included a comment that “The staffing levels seem better at the moment so the residents can do more activities and things”. The acting manager reported that she is monitoring levels of engagement for service users whilst based at the home; this is discussed within staff team meetings. The home had been decorated with flags and bunting for the World Cup. The acting manager explained that, although staff could not be sure of service users’ understanding of the event, an occasion had been made of the England games and the service users appeared to have enjoyed this. There was evidence in service user records that regular contact with family and friends is supported for four out of five service users. The acting manager reported that enquiries have been made about accessing advocacy services for a service user with no family contact. Evidence of this was seen in records. Relatives of service users who completed a relative comment card all stated that they were made to feel welcome at the home and that they could visit their relative in private if they wished to do so. Progress made at the previous inspection with regard to recognising service users’ rights and promoting independence has been maintained and this is positive. Viewing holes remain in the service users’ bedrooms who are secluded as a method of managing challenging behaviour, although there has only been one occasion of seclusion since the last inspection and this did not occur in a bedroom. There was evidence in staff meeting minutes that this has been reviewed. This should continue to be kept under review and the viewing holes should be filled/removed as soon as they are no longer necessary in order to protect the privacy and dignity of the service users. None of the service users living at Lindley cottage have a key to their bedrooms due to their 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 showed that a varied diet is offered, although more detail should be included to demonstrate that service users are offered the recommended five portions of fruit and vegetables a day. There was a good supply of fresh fruit and vegetables at the home at the time of the site visit. The acting manager reported that she is looking at developing a food book to include pictures of meals along with the recipes. This will help service users to make a choice about what they would like to eat. A support worker who started work at the home in December is a qualified chef and it was reported that he is making efforts to widen the repertoire of meals offered. A selection of cookbooks has been purchased to assist staff in this area. The acting manager reported that service users have a choice of breakfast. This is offered by showing service users a range of cereals, jams etc. Service users are not Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 14 offered a choice of evening meal though it is anticipated that this will be introduced when the food book has been established. This will be checked at the next site visit. There was sufficient food supplies and opened foods were labelled appropriately in the fridge. Staff reported that those 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.V296158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Some service users receive personal support in the way they prefer or require. Further information is necessary in some individual care plans to ensure that all service users 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 more care in record keeping would improve practice in this area. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Personal support was observed to be offered discreetly and with sensitivity. Since the last inspection visit, significant progress has been made in the development of clear personal support plans for some service users. Two personal support plans were examined as part of the site visit. One was found to contain excellent detail that set out the service user’s preferred routine and likes and dislikes. The other, however, was less clear and detailed and further development is necessary to ensure that the service user’s needs are met in the way that they prefer. This was discussed with the acting manager at the time. Service users each have allocated keyworkers and staff spoken to were clear about their role as a keyworker. The acting manager described how the Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 16 amount of personal care time given to an individual who sometimes requires physical intervention from staff had been increased in order to create opportunities for positive physical contact. This is reported to have had a positive impact and allowed for good relationships to be built. It is positive that staff have identified the potential negative impact of physical intervention on relationships between the service user and staff, and have taken a proactive approach in an attempt to increase opportunities for positive interactions. Since the last inspection visit, the toilet roll holder in the first floor toilet has been repaired. Both toilets had toilet roll, and soap and hand towels were available in the ground floor toilet. 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. Feedback from a healthcare professional who completed a comment card was positive. The information received indicated that the home communicates clearly and works in partnership with the health professional, is able to see service users in private, staff demonstrate a clear understanding of the care needs of the service users, specialist advice is incorporated into the care plan, service users’ medication is appropriately managed, management and staff take appropriate decisions, there is always a senior member of staff to confer with, complaints about the home have not been received by the health professional, and they are satisfied with the overall care provided at the home. Since the last inspection visit, a newly qualified nurse has been given the responsibility for checking that all medication records are up to date and that guidelines are in place where necessary. This is done on a weekly basis. Clear guidelines instructing staff when to administer as required or ‘prn’ medication were in place. A list of all medication prescribed for service users and the reasons for this was available in respect of each service user; this is good practice. Of three medications checked, there were discrepancies with two. The acting manager reported that she monitors errors and has informed nursing staff that a daily audit rather than a weekly audit will be introduced if there continues to be discrepancies. A requirement has been made in respect of safe practice concerning medication. Medication is stored securely at this home. Lindley Cottage DS0000001117.V296158.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 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. Some care plans and behaviour management plans provide excellent information to ensure that service users are protected from potential harm and abuse. Further development is necessary in some areas. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: A satisfactory complaints procedure is in place. This is also available in symbol format. The pre-inspection questionnaire indicated that one complaint had been received at the home in the last twelve months. This had come from a member of the public expressing concern about the welfare of a service user at the home. Records of the complaint and action taken had been kept and evidence that the complaint had been dealt with satisfactorily was seen. The acting manager was able to give a clear account of the concerns and an explanation about the events. No further action is necessary. Completed relatives’ comment cards indicate that three of the four respondents are aware of the complaints procedure. Two stated they had never had to make a complaint, one stated that they had made a complaint and one stated that they “occasionally make a complaint about minor matters that are easily resolved”. 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. Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 18 Concerns have previously been raised at this home regarding the management of challenging behaviour. Since the last inspection visit, behaviour management strategies in relation to a service user who requires significant support in managing his behaviour have improved. Clear guidance is in place so that staff can more easily identify triggers to behaviours and avoid some challenging incidents occurring. Staff spoken to could describe how they would respond to challenging incidents; this was in line with the agreed guidance. A staff member commented that the guidelines have helped to provide a consistent approach to a service user and that the atmosphere in the home was much calmer. The atmosphere at the home was observed to be much calmer than on previous visits. 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. It was noted that behaviour management guidelines for another service user were unclear, and there was no clear rationale for restrictions being placed upon the individual. This was discussed with the acting manager at the time. This needs to be addressed, along with clearer information being added to the care plan and risk assessments for the individual. The acting manager reported that all staff had received ‘safe hands’ training in physical intervention. Senior staff within the organisation have almost completed their training to become physical intervention trainers accredited by the British Institute of Learning Disabilities, and this is a positive step. As part of the assessment procedure, a number of staff have completed a two-day basic introduction relating to physical intervention and de-escalation delivered by the St Anne’s physical intervention trainers. The acting manager reported that, when the trainers have completed their course (anticipated to be complete by August 2006), all staff would attend the two-day introduction within twelve months. The acting manager reported that the plan to have a specialist consultant work with the staff team regarding managing and understanding individual service users’ behaviours had not been achieved. Service user monies that were examined could be reconciled with records kept. Receipts of purchases were available and record keeping was clear and up to date. Lindley Cottage DS0000001117.V296158.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 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 clean, comfortable environment. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: All communal areas of the home, the bathroom, toilets and laundry were seen as part of this site visit. The home was clean and free from offensive odour at the time of the visit. The sofas in the lounge are in need of replacement and the acting manager reported that she is in the process of obtaining quotes to replace this furniture. Sensory equipment has been removed from the lounge since the last visit; the acting manager reported that this was due to health and safety concerns. Plans to move the office/sleep in room to a room off the laundry and turn the existing office into a quiet lounge are being discussed. The laminate flooring on order for a service user’s bedroom at the last inspection visit has now been fitted. The radiator cover in the lounge was damaged and must be repaired. The acting manager reported that this was on the maintenance list. She reported that the maintenance department were short staffed and that this had impacted on the level of service offered to the home. Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 20 All communal areas of the home remain accessible to service users with the exception of the first floor bathroom. As previously mentioned in this report, it is planned that, upon completion of refurbishment, this will remain open and accessible to service users. 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. Evidence that this has been reviewed was seen in staff meeting minutes where staff agreed that they would remain in place for the time being. This must be kept under regular review and the view holes removed or filled in at the point they are no longer required/used. 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.V296158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 A committed, consistent staff team supports service users. Staff have received relevant training. Quality in this outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Staff on duty at the time of the site visit presented as approachable, positive and comfortable with service users. Staff spoken to were able to demonstrate an understanding of behaviours exhibited by some service users and had a good knowledge of their needs. Of six care staff, none have completed NVQ level two or above, although two are working towards NVQ level three in care. Since the last inspection visit, two new care staff have been appointed and both are in the process of completing the Learning Disabilities Award Framework induction and foundation programme. The acting manager reported that both would start NVQ level three in July 2006. It is recommended that at least 50 of care staff have achieved NVQ level 2 in care; therefore a recommendation has been made in respect of this matter. Since the last inspection, all vacant posts have been filled and there is now a full complement of staff. The acting manager commented that the two new staff are both men and this seems to have had a positive impact on service Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 22 delivery as two of the service users living at Lindley Cottage are men. Staff spoken to said that having a full complement of staff has had a positive impact on the service as a consistent staff team is supporting service users; staff morale was described as good. Additional hours available for an individual service user (37 hours) is covered using the home’s own staff working additional shifts if they choose to do so, or bank staff employed by St Anne’s. The same two bank staff are used in order to provide a consistent approach to the service user. The acting manager said that this arrangement is working well as the hours can be used flexibly depending on what the service user has planned and whether or not the service user wants to go out. Feedback from relatives of service users living at Lindley Cottage indicated that that, in their opinion, there are sufficient staff on duty. One relative noted “the staffing levels seem better at the moment so the residents can do more activities and things”. Staff recruitment records are stored centrally and the Provider Relationship Manager from CSCI examines these. The acting manager explained that, for all new staff, a record that all the required pre-employment checks have been completed would be kept at the home. The pre-inspection questionnaire indicates that, since the last inspection visit, all staff have attended mandatory training including health and safety, food hygiene, movement and handling, emergency aid and safe hands. The acting manager confirmed that this had taken place. Additional training that has been attended by some staff includes managing change, physical intervention conference provided by the British Institute of Learning Disabilities (BILD) and coaching and mentoring. Staff training records were not examined at this site visit, although staff spoken to confirmed the training they had attended. The organisation’s new training programme for the coming year has been received at the home, and the pre-inspection questionnaire states that staff are discussing their training needs in supervision. NVQ training is ongoing. Lindley Cottage DS0000001117.V296158.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39,42 A suitably qualified acting manager is running this home. Lindley Cottage is a well managed home. Satisfactory quality assurance and monitoring systems are in place at this home; a system for publishing the results is under discussion. The health and safety of staff and service users is protected in most areas; further development of risk assessment and behaviour management strategies is required in some areas. Quality in this outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Since the last inspection visit, the registered manager has left the home, and the acting manager has been appointed as the home’s manager on a permanent basis; she has still to apply to CSCI to become registered. The Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 24 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. All staff spoken to gave positive feedback about the management style and described the manager as approachable and supportive. The acting manager reported that she had been on a range of relevant training since the last inspection visit. The acting manager communicates a clear sense of direction and leadership. She has had a positive influence on the service and is able to prioritise areas that require development and improvement. Staff reported an ‘open culture’ at the home where discussion is encouraged. Questionnaires are sent to relatives/friends of service users seeking their views about the quality of service offered; service users at this home would be unable to contribute to this due to the level of learning disability. The acting manager reported that the senior management team were looking at how the information collated from the questionnaires could be fed back to service users in a meaningful format. The home has an annual development plan that is available in the home. The service manager or a registered manager from another of St Anne’s homes conducts the monthly provider visits that are required under the Care Homes Regulations. A copy of the report of these visits is sent to the CSCI. Additional detail should be added to these reports to make clear what the issues are. For example, under the section ‘observation on property/maintenance issues’, a comment ‘downstairs toilet’ has been made. The following month, the report states ‘ toilet still requires attention’, and the following month reports ‘no major problems’. It is unclear from the report what the problem is and whether or not it has been rectified. St Anne’s have a format that is used to complete the monthly visit reports, however it was noted that a number of areas on the form had not been completed as intended therefore not providing the necessary information. This included information in relation to accidents involving service users and staff. It is recommended that more detailed information be included in the reports of monthly visits by the provider. Feedback from four relatives and one healthcare professional received in comment cards all stated that they were satisfied with the overall care provided at Lindley Cottage and this is positive. The pre-inspection questionnaire indicates that health and safety checks are conducted at the required intervals. St Anne’s have confirmed in writing that the necessary steps have been taken to address matters brought to their attention following a fire safety inspection conducted in December 2005 by the fire safety inspector. The pre-inspection questionnaire also confirms that fire safety checks and maintenance have been carried out. A student nurse on placement at the home confirmed that she had received fire safety instruction on her first day at the home and had watched the fire safety video. 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 Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 25 management strategies and risk assessments. This is discussed earlier in the report. Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 26 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 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 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 3 2 X 3 3 3 X X 2 X Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 27 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 YA42 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 (if required), 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. Timescale of 15/03/06 unmet There must be clear evidence of those that have been consulted and agreed to the use of physical intervention and seclusion as part of an individuals care plan. 2. YA9 YA42 13(4) Detailed risk assessments 15/08/06 must be in place for all service users. Some risk assessments currently in place must be reviewed to ensure they contain sufficient detail. DS0000001117.V296158.R01.S.doc Version 5.2 Page 28 Timescale for action 15/08/06 Lindley Cottage Timescale of 15/03/06 unmet. 3. YA20 12(1)a,b 13(2) The registered person must ensure that accurate medication records are kept. 31/07/06 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 YA32 YA37 YA39 Good Practice Recommendations The registered person should continue working towards 50 of all care staff achieving NVQ level 2 or above. The acting manager should submit an application to the CSCI in order to become registered. Regulation 26 reports should contain more detail. Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 29 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 Lindley Cottage DS0000001117.V296158.R01.S.doc Version 5.2 Page 30 - 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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