Inspection on 17/01/06 for Montague Drive

This inspection was carried out on 17th 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 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

Montague Drive 21/09/09

Montague Drive 19/09/07

Montague Drive 13/09/06

Montague Drive 08/06/05

Montague Drive 25/01/05

Montague Drive 27/01/04

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 Montague Drive 20 Montague Drive Leeds West Yorkshire LS8 2PD Lead Inspector Hebrew Rawlins Unannounced Inspection 17th January 2006 10:30 Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 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 Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 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. Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Montague Drive Address 20 Montague Drive Leeds West Yorkshire LS8 2PD 0113 240 0062 0113 2400062 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.c-i-c.co.uk. Community Integrated Care Ms Eileen Mary Noland Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th June 2005 Brief Description of the Service: The South Yorkshire Housing Association owns the property at Montague Drive. The care and services are provided by Community Integrated Care which is a registered charity caring for people with special needs. Montague Drive is a detached bungalow located within 2 miles of Leeds City Centre and is at the top of a quiet cul de sac. There are a wide range of shops and leisure facilities within easy reach of the property. The home has 4 bedrooms. All are single rooms and have a washbasin. They are decorated to individual taste and choice. Service users are encouraged to buy personal items for their own use, which helps to create a homely atmosphere within the establishment. Service users are encouraged to make full use of the entire house. Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector between 10.30am and 3.15pm carried out this unannounced inspection. The purpose of the visit was to check compliance with the standards and outcomes for residents. The manager was present and was given feedback at the end. Time was spent looking round the home, observing practices, talking to residents, examining records and discussions with the manager and staff. Records inspected included care plans, medication records and staff records. The last inspection was also unannounced with the previous registered manager. This is the first with this manager who is awaiting registration with the Commission for Social Care Inspection. Requirements from the last inspection have been addressed. However a number of shortfalls in the standards at this inspection have been identified. What the service does well: What has improved since the last inspection? What they could do better: Menu sheets were not always filled in and there were no evidence to show that individual choice was taken into account. The recording of meals should be available as evidence that residents are getting a good meal at all times. In the care plans there were a number of areas where improvements could be made in relation to health care needs. Risk assessments mist be reviewed regularly and resident’s food and fluid monitored. Care plans must clearly show Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 6 what action has been taken by staff to make sure resident’s personal care needs are met. The fire alarm system must be tested and record kept even when the manager is on holiday and staff meeting should start taking place again. 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. Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 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 Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 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): None of these standards were assessed at this visit. EVIDENCE: Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 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): 7, 8, and 9. Because of residents communication and sometimes-physical disabilities staff help resident choices by skilled observation. EVIDENCE: Montague Drive residents often require staff to interpret their speech given their individual communication difficulties. This is done through trained observation, and by the involvement of the multidisciplinary team inclusive of professional workers not directly employed by the home that are able to interpret service users speech Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 15 and 17. Residents are encouraged to be part of the decision making process and make choices about their lifestyle. The range and frequency of activities provided is good and there are opportunities for residents to go out. The food menu must be kept up to date. EVIDENCE: Residents are supported to maintain contact with family and friends and visitors are welcomed at the home. A good, varied and nutritious meal was served on the day of the visit. However menu sheets were not always filled in and there were no evidence to show that individual choice was taken into account. The recording of meals should be available as evidence that residents are getting a good meal at all times. All residents said they enjoy the meals. Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 11 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 and 20. Residents care plans require more work. Risk assessments must be regularly reviewed and residents nutritional needs monitored. EVIDENCE: Case tracking was done for two residents which involved looking at their care records and medication charts. In the care plans there were a number of areas where improvements could be made in relation to health care needs. The records showed evidence of regular reviews not taking place. The last recorded risk assessment was 15/11/04. One resident risk assessment identified the need to lose weight to aid mobility. Yet there were no records to show that this resident food/fluid intake was being monitored. The care records should clearly show what action has been taken by staff to make sure this resident’s nutritional needs are met and to prevent serious consequences to her health. The personal care record of one resident was not completed for 4 days. Medication ordering and administration systems were looked at. Detailed records show the medication ordered and received for each resident. Administration charts were completed and resident said that they were well looked after and described the staff as “great”. Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 12 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): None of these standards were assessed at this visit. EVIDENCE: Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 13 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, 26, 28 and 30. General maintenance is good any works identified are dealt with promptly. The home is clean and free from malodours. EVIDENCE: A tour of the building took place. The shared areas were noted to be clean and comfortably furnished. The house is large enough for people to have their own personal space and to be able to spend time alone if they wish. There was evidence of resident’s personal possessions in all of the bedrooms. Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 14 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): 34, 35 and 36, The home has a robust interview process when recruiting staff and training is still high on the home list. EVIDENCE: Several staff files were looked at. References were in files and Criminal Records Bureau checks were completed. Records showed staff had done training on moving & handling, first aid, principles of care, food hygiene, stress, adult protection, fire/health & safety they have also had training on person centred planning. Staff has received regular supervision. Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 15 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): 41, 42 and 43. The staff respects the manager, she has not been the manager of the home for long and is working hard to provide a quality service for residents. There are a few things she needs to address like risk assessments and several issues highlighted in the body of this report. EVIDENCE: The Commission for Social Care Inspection has received the manager application for registration and this is being process. It is evident from the records looked at that the manager has some catching up to do. The fire alarm system must be tested and record kept. Staff meeting should start taking place again, care plans reviewed and menus kept. Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 16 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x x x x x Standard No 22 23 Score x x ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score x 3 3 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x 3 x 3 x 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 x 15 3 16 x 17 Standard No 31 32 33 34 35 36 Score x x x 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Montague Drive Score 2 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x 2 2 2 DS0000001482.V273238.R01.S.doc Version 5.0 Page 17 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 YA17 Regulation 16 Requirement The recording of meals must be available as evidence that residents are getting a good meal at all times. Risk assessments must be regularly reviewed. The personal care record of residents must be completed. The fire alarm system must be tested and record kept. The manager must be registered by CSCI. Timescale for action 01/04/06 2 4 5 6 YA18 YA18 YA41 YA43 14 15 17 9 01/04/06 01/04/06 01/04/06 01/04/06 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 Refer to Standard YA38 Good Practice Recommendations Regular staff meetings should take place. Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Montague Drive DS0000001482.V273238.R01.S.doc Version 5.0 Page 19 - 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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