Inspection on 30/08/05 for Smithies Moor

This inspection was carried out on 30th August 2005.

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 but made no statutory requirements on the home.

Other inspections for this house

Smithies Moor 17/04/07

Smithies Moor 06/12/05

Smithies Moor 18/01/05

Smithies Moor 21/07/04

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 Smithies Moor 46 Smithies Moor Lane Birstall Batley WF17 9AN Lead Inspector Alison McCabe Unannounced 30 August 2005 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 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 Stationary 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. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Smithies Moor Address 46 Smithies Moor Lane Birstall Batley WF17 9AN 01924 474453 01924 474453 Telephone number Fax number Email 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 Annes Community Services Miss Judith Elizabeth Cooper Care Home with Nursing 6 Category(ies) of people aged 18-65 with a learning disability registration, with number of places Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: Conditions of this registration are listed on the registration certificate displayed at the service. Date of last inspection 18/1/05 Brief Description of the Service: 46 Smithies Moor Lane is a care home registered to provide nursing care and accommodation for six adults with learning disabilities. The home is operated by St Anne’s Shelter and Housing Association, a charitable organisation.The property is a large detached bungalow, which stands in its own grounds, overlooking countryside. There are parking facilities at the front of the home and attractive gardens to the rear.The home is located in a residential are on the outskirts of Birstall. Local shops, a post office and community facilities can be found within 1 mile of the home. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and took place between 3.30pm and 5.50pm. One inspector conducted this inspection visit. The inspector had the opportunity to talk to two service users during the course of the inspection. The inspector also talked to the manager, deputy manager and a nurse on duty. The inspector examined records, and accessed communal areas of the home. This is a well run home providing good care to six service users with learning disabilities. The inspector focused on core standards only at this inspection. What the service does well: What has improved since the last inspection? A service user has been helped to grow fruit and vegetables in the garden. The quiet lounge has been redecorated. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 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 standard(s) None of the above standards were assessed at this inspection. EVIDENCE: Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 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 standard(s) None of the above standards were assessed at this inspection. EVIDENCE: Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 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 standard(s) 12,13,14 Service users are offered opportunities to access community facilities on a regular basis. A good range of leisure and educational activities is available at this home. EVIDENCE: The manager told the inspector that some of the service users attend day services and a range of college courses. One service user had been at day services on the day of inspection. A range of leisure activities is offered to all service users both in the local community and within the home. On the day of inspection, two service users had gone on a day trip to Bridlington, and two service users went out for their evening meal. The manager reported that all service users have had a holiday this year. The home has its own transport that enables easy access to the community. The inspector saw evidence of available activities within the home including, games, TV and stereo equipment and a computer. One service user was supported to dig up potatoes from the garden that she had grown. A vegetable plot has been developed since the last inspection, and a service user has enjoyed growing fruit and vegetables. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 11 The manager told the inspector that a service user had made a rhubarb crumble using the rhubarb she had grown in the garden. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 12 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 standard(s) 20 Administration, storage and recording of medicines are well managed at the home. EVIDENCE: Medication records and stock were examined. Medication for one service user did not reconcile with records kept, however the manager was able to identify where the error had occurred and take appropriate steps to rectify this. Medicine management in the home is good. Staff complete a daily check and a further weekly audit is completed of all medicines. Evidence of this was seen in the records. This system allows for any errors to be identified quickly and appropriate action to be taken. Clear guidelines and instructions are in place regarding the administration of prn medication. Medication is stored securely in the home. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 13 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 standard(s) 22,23 The home has a clear complaints procedure that is available to service users and their relatives. Good procedures and care practice at this home protects service users from harm and abuse. EVIDENCE: The manager reported that no complaints have been received at the home in the past twelve months. A satisfactory complaints procedure that includes timescales for dealing with a complaint is in place at the home. Since the last inspection the manager has written to all relatives of service users to remind them of the complaints procedure. This was a recommendation at the last inspection. The inspector was unable to confirm service users understanding of the complaints procedure. A satisfactory adult protection procedure, including whistle blowing, is in place in addition to the Kirklees Vulnerable Adult procedures. A comprehensive physical intervention policy and procedure is available that is in line with Department of Health guidance. The manager and staff told the inspector that agreed physical intervention plans were still in place and continue to be used occasionally, to good effect. The manager and a staff member described deescalation techniques that are used successfully with a service user. Staff have received relevant training in de-escalation and physical intervention techniques. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 14 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 standard(s) 24,30 Service users live in a clean, comfortable home that has plenty of space. Two service users have single bedrooms and there are two shared rooms each accommodating two service users. Adapted bathing facilities are provided. EVIDENCE: The inspector had the opportunity to look around communal areas of the home. The home is in a good state of repair and is domestic in style. The home is comfortable and is furnished to a satisfactory standard. The quiet lounge has been redecorated since the last inspection. The home provides accommodation to six service users in two single bedrooms and two shared bedrooms. The organisation is exploring how the home might be adapted to provide single accommodation to service users. The shared rooms have been arranged so that separate areas are provided using screening and wardrobes. Adequate communal space is provided including a good-sized lounge with a raised dining area, kitchen and quiet lounge/computer room. An adapted bathroom and shower room are provided. There is a large wellmaintained garden to the rear of the property and a car parking area to the front. There is a small sleeping in room/office for staff. The home was clean and free from offensive odours. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32,35 Staff working at the home have relevant qualifications and experience. Relevant training is provided to staff. Staff have good relationships with service users. EVIDENCE: The inspector did not fully assess standard 34, however the manager reported that the organisation is still in discussion with CSCI regarding recruitment records being held centrally. Records required under the Care Homes Regulations are not all available within the home. The requirement made at the last inspection regarding this has therefore been brought forward, and the inspector will assess this in full at the next inspection. Staff at the home have a range of skills and experience. Of six care staff, four have achieved NVQ level 3, one has achieved NVQ level 2 and is currently working towards level 3 and one carer is completing the Learning Disabilities Award Framework foundation training and will then commence NVQ training. There are five qualified nurses (learning disability), including the manager, working at the home. There is a comprehensive training and development plan in place. Training that staff have received includes, movement and handling, first aid, food Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 16 hygiene, adult protection, health and safety, use of rectal diazepam, epilepsy, bi-polar disorder. This is in addition to NVQ training, which is ongoing. New care staff complete the Learning Disability Award Framework induction and foundation training. Care practice observed was positive. Staff communicate effectively and respectfully with service users, and service users appeared to be relaxed in the company of staff. It was evident at the inspection that staff have positive relationships with the service users and know them well. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 17 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 The health, safety and welfare of service users are protected at this home. EVIDENCE: Records regarding health and safety matters were in good order. There was evidence in the records that the required checks and maintenance of safety and specialist equipment is carried out. Evidence that regular fire drills are carried out to ensure that service users and staff are aware of the procedure was seen in the records. It was noted that water temperatures are often several degrees below the recommended 43 degrees centigrade and it is recommended that these be adjusted. Risk assessments regarding health and safety matters are up to date and available. All staff receive training in health and safety. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 18 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 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score x x x x x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 3 x x x Standard No 31 32 33 34 35 36 Score x 3 x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Smithies Moor Score x x 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 19 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 34 Regulation 19 Timescale for action The registered person has Timescale documentary evidence indicating of 31/3/04 that anyone employed by them and or another person who is 15/3/05 working at the home is fit to unmet. work there. 31/10/05 A record is kept in the home in Timescale respect of each person of 31/3/04 employed, which contains all the and information stipulated in 15/3/05 Schedule 4(6) of the Care Homes unmet. Regulations 2001. These records 31/10/05 are available for inspection. Requirement 2. 34 17(2) 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 42 Good Practice Recommendations Hot water should be delivered close to 43 degrees centigrade. Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 20 Commission for Social Care Inspection 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 Smithies Moor 20050830 Smithies Moor Lane IR YA J51 v247067 s1096.doc Version 1.40 Page 21 - 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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