Inspection on 23/02/06 for Reinwood Avenue

This inspection was carried out on 23rd February 2006.

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 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

Reinwood Avenue 31/10/07

Reinwood Avenue 11/01/07

Reinwood Avenue 21/02/05

Reinwood Avenue 20/08/04

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 Reinwood Avenue 26 Reinwood Avenue Leeds West Yorkshire LS8 3DP Lead Inspector Sue Dunn Unannounced Inspection 23rd February 2006 13:00 Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Reinwood Avenue Address 26 Reinwood Avenue Leeds West Yorkshire LS8 3DP 0113 273 0083 0113 2730083 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 Mrs Lynda Whitehead Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th September 2005 Brief Description of the Service: The home is a large detached bungalow owned by South Yorkshire Housing Association. It is situated in a residential area close to the Oakwood area of Leeds. The house and gardens are well maintained and indistinguishable from other house in the street. Local shops and amenities are nearby. A regular bus service into the city centre passes the end of the road. The home has its own car use of which is dependant on staff who can drive being on duty. Bedrooms are of a good size with ample communal space for the 3 people the home can accommodate. The house and garden have facilities for service users who use wheelchairs. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This report is based on an unannounced inspection carried out by one inspector. The inspection started at 13:15pm and took place over a period of 3.30 hours. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard and in the best interests of the two people living there. One resident was at home at the time of the inspection with three care staff, one of whom had to leave to escort the other service user back from his morning activities. The manager was not on duty but a senior care worker came on duty during the afternoon when the shifts changed and assisted with the inspection. The two care files and a selection of records was inspected, the service users and staff were spoken with and observed and the building was briefly inspected. The Statement of Purpose is under review. A copy of this should be sent to the CSCI when completed. Most of the requirements identified during this inspection arise from the most recent admission and the overall organisation of the records. What the service does well: What has improved since the last inspection? Cluttered areas in the bathroom and the laundry had been cleared. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 6 The work recommended by the fire safety officer has been completed and approved. 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. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1 Service users or relatives are provided with information to enable them to make an informed choice about the home. It is understood that the Statement of purpose is being redesigned in a format more suitable for the service users as recommended at the last inspection. EVIDENCE: The inspector was informed that the manager is in the process of reviewing the Service user guide and Statement of Purpose in a format to take into account the communication needs of the residents. A copy of this should be sent to the CSCI when it is completed Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9,10 The staff had a good understanding of residents care needs due to the small staff team and number of residents. This was not fully evidenced in the care plans, which in one case did not show evidence of any goal setting and forward planning to provide for social, recreational and personal development. Staff try to understand and respond to the residents preferences through observation and familiarity. EVIDENCE: The care files of the two people who live in the home were inspected. The files contained a good quality of information related to care needs but as access to the information involved looking through several books it was not easy to find for anyone not accustomed to the system. For example one file contained 5 books covering and overlapping different areas of care. One file for the most recently admitted resident included good guidance on how to deal with presenting behaviours. (It was apparent from observation of an agency employee that she was using the guidance when working with the service user) but there was no formalised plan for development or to guide activity for maintaining quality of life. Key workers had gathered information on loose leaf sheets which were found in the file and which should have been Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 10 transferred to a more formalised plan of care. The inspector was told they were waiting for more information before forming a care plan. This indicated a lack of understanding that care plans should develop, be reviewed and amended. There was information in one file which gave guidance on the meaning behind gestures and words used by the service user. The staff displayed good knowledge of each person’s method of communication and used this to try to respond to each residents needs. Risk assessments had been done for hazards in the house for one of the service users but these were undated and unsigned and there was no clear action plan. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,14,15,17 One resident had the opportunity to participate in social and leisure activities. The care plan for the other person had not been fully developed. More should be done to improve the quality of life and opportunities for this resident. A good, varied and nutritious diet using fresh produce takes into account individual choices. EVIDENCE: One service user had risk assessments for Out and About activities, daily activities and the environment. These had been reviewed but simply with a date and initial. The reviews must include comments based on the judgement and justifying the decision of the person undertaking the review. The same service user was out during the morning at TACT. There was a good quarterly progress report from Tact describing his activities. One person has regular visits from his family and the other has family contact and an independent advocate to represent his interests. The home has a people carrier vehicle but only two staff are able to drive therefore outings are restricted to when they are on duty Both residents have their own communication diary. Judging by the entries the most recent resident appeared to do little more than listen to music, sit in front of the TV or go to local shops in fine weather. The staff should look at ways in Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 12 which he can take part in activities beyond the home and appropriate to his age. Staff were making the evening meal which smelt ‘mouth watering’. The fridge and freezer were well stocked with fresh produce. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 13 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 The health care needs are identified and monitored and the home works with other health care professionals for the benefit of residents . Staff are aware of the residents’ needs and there is good communication within the staff group. Residents are treated with dignity and their privacy maintained at all times. EVIDENCE: The Health plan booklets appeared to be an area in which staff showed more confidence. The information in these showed health checks, contact with health care support staff, health care appointments and guidance on PRN medication. However, the dates of the action plan in one file were unclear and there was no evidence to show if guidance on seizures had been updated since it was done in 1999. Notes from a review had been left loose in the file increasing the risk that they may be misplaced. The home has a medication policy with a list of ‘homely remedies’ seen in the medication administration file. Neither resident is able to manage his own medication. The details of a resident who no longer lives in the home was still in the file. This needs transferring to the archived notes. Records showed residents receive regular support from other health care professionals. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 14 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 The home has a complaints and adult protection procedure on which staff have had training to ensure service users are protected. EVIDENCE: The home has a complaints procedure. The manager is currently reviewing this as it is not in a format which is sympathetic to the communication needs of the type of residents the home accommodates. A member of staff explained that one resident shows his anger if something is wrong. Staff have to be vigilant and identify the cause of his complaint by ‘trial and error’. The advocacy service is used to ensure peoples’ rights are recognised. The organisation has provided training for staff on the Protection of Vulnerable Adults. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 15 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): 24,25,27,28,29,30 The home offers a clean, safe, environment for the residents and provides appropriate bathing, toilet facilities and specialist equipment. Systems are in place for the upkeep and maintenance of the building Some work is needed to maintain satisfactory levels of odour control in all parts of the home EVIDENCE: The home, which is on one level is domestic in style, clean and well furnished. There is ample communal space and bedrooms are generous in size. There was an unpleasant odour in one room not found on the last inspection. The explanation for this and observation of the resident indicated that night staff may not be as vigilant as required. It is understood the carpet is to be replaced. People are assessed for specialist equipment on an individual basis. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 16 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): 32,33,35,36 Staffing numbers and experience ensure that residents’ needs can be met. However staff would benefit from further training on care planning. EVIDENCE: Staffing levels have been increased to meet the needs of the most recent service user who requires the support of two members of staff. This has been achieved by the use of agency staff as the manager continues the difficult task of recruitment. The manager aims to use the same agency workers to give continuity of care for the residents. Agency staff are currently providing waking night cover. A new permanent care worker is to start work within the next two weeks and two more have been approved, subject to satisfactory safety checks. An agency worker described her experience and the introductory induction to the home. This was said to involve a tour of the building, being told about service users preferences and how they liked to be cared for and reading the care file. The worker had not had any in house instruction on fire safety. As there was no evidence of this induction in the home there is a danger that each person thinks someone else has done it. It is recommended that an induction check list is introduced for any staff working on a sessional basis. Staff meetings are held monthly and supervision is pre booked around the rota. The organisation is to introduce Person Centred Planning (PCP’s) and in house staff training is to be arranged. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 17 Staff were observed to have a kind friendly approach towards residents. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 18 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): 37,38,41,42, Satisfactory arrangements were in place for the management of the home and there was a very ’personalised’ approach to the care of the residents. The health safety of residents is protected but there is room for improvement in the organisation and storage of records EVIDENCE: The home’s service manager has recently left. The role is being covered by an ‘acting’ service manager but not all staff appeared to be aware of the management arrangements. Senior managers work an on call rota for supporting staff in the home. A copy of this was on the office wall. The manager was on leave on the day of the inspection. It was said that much of her time recently has been spent on the recruitment and selection of suitable staff. There is room for improvement in the way documentation is managed and stored in the home as one of the people in charge of the home at the time of the inspection was not sure where all the records, which were spread across different rooms in the home, could be found. Information on care would be better stored in one sectioned file for each resident with a sub file for supporting information. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 19 The records showed that the last fire drill took place in September. There were ticks against the names of the staff who attended. The staff fire safety training records, health and safety checks and records confirming staff had read policies and procedures were inspected. Signatures and comments were illegible as was some of the writing in the daily diaries. Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 20 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 2 2 x 3 x 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 4 25 4 26 x 27 3 28 4 29 3 30 2 STAFFING Standard No Score 31 x 32 3 33 3 34 x 35 2 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 3 3 LIFESTYLES Standard No Score 11 x 12 2 13 x 14 2 15 3 16 x 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 3 3 x x 2 3 x Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 21 Are there any outstanding requirements from the last inspection? Yes –Still within timescale 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 YA1 Regulation 5 and 6 Requirement The statement of purpose and service user guide must be reviewed annually and be in a format suitable for the needs of the people for whom it is intended. Within timescale Each resident must have a care plan which sets out their full range of needs There must be evidence to show that each service user has the opportunity to take part in age, peer and culturally appropriate activities Each service user must have the opportunity to engage in appropriate leisure activities All parts of the home must be kept free of unpleasant odours Staff training must include the effective use of care plans The organisation and storage of records must be reviewed Timescale for action 31/03/06 2 3 YA6 YA12 15,17 12 30/04/06 30/04/06 4 5 6 7 YA14 YA30 YA35 YA41 12 16 15,18 17 30/04/06 30/04/06 31/05/06 31/05/06 Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 22 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 YA41YA6 Good Practice Recommendations It is recommended that all information concerning residents’ care be held together in one main file Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 23 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 Reinwood Avenue DS0000001401.V283247.R01.S.doc Version 5.1 Page 24 - 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. 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