Inspection on 06/12/05 for Smithies Moor

This inspection was carried out on 6th December 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Smithies Moor 17/04/07

Smithies Moor 30/08/05

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 West Yorkshire WF17 9AN Lead Inspector Alison McCabe Unannounced Inspection 6th December 2005 3:10pm Smithies Moor DS0000001096.V271183.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 Smithies Moor DS0000001096.V271183.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. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Smithies Moor Address 46 Smithies Moor Lane Birstall Batley West Yorkshire WF17 9AN 01924 474453 01924 474453 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 Miss Judith Elizabeth Cooper Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Can accommodate one named service user with learning disabilities aged over 65 years. 30th August 2005 Date of last inspection 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 Community Services, a charitable organisation. The property is a large detached bungalow which stands in its own grounds, overlooking the countryside. There are car-parking facilities at the front of the home and attractive gardens to the rear. The home is located in a residential area on the outskirts of Birstall. Local shops, a post office and community facilities can be found within one mile of the home. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was conducted by one inspector between 3.10pm and 5.25pm. As part of this inspection, records were sampled, water temperatures checked and discussion took place with the nurse in charge, a support assistant and two service users. The inspector also spent time observing care practice. The findings of the inspection are positive. This is a well run home providing good quality care. Service users appear to be well cared for and comfortable at the home. The home looked very festive with a Christmas tree and decorations. What the service does well: What has improved since the last inspection? New hoisting equipment has been installed in order to meet the needs of an individual at the home. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 6 Hot water temperatures have been increased and are at the recommended level. 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 DS0000001096.V271183.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 Smithies Moor DS0000001096.V271183.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): 2 Service users’ needs are assessed before they move into the home. EVIDENCE: No new service users have been admitted to the home for some time, however pre-admission assessments are in place for those service users currently accommodated at the home. A service user whose needs have changed significantly over the last year has been re-assessed and the individual care plan revised to reflect his changing needs. Smithies Moor DS0000001096.V271183.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): 6,7,9 Care planning and risk management are good at this home. Good support is offered to service users to enable them to make decisions about their lives. EVIDENCE: Individual care plans contained excellent detail of how service users’ needs should be met. These were easy to follow and gave clear guidance to staff. There was evidence that service users had been involved in person centred planning meetings and that regular reviews take place. Records showed evidence that action plans were implemented and, if they had not been, there were clear records to indicate the reasons why not. Relevant specialists are accessed when necessary and advice and recommendations made are reflected in the individual plans. Quick reference guides have been developed where specific personal care routines have been put onto laminated cards to support agency or bank staff in helping service users with their routines. These were detailed and help to ensure that consistent care is provided to service users in the event of temporary staff covering shifts. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 10 Through examination of records, discussion with staff and observation of care practice, it was evident that service users are supported to make decisions about their lives wherever possible. For example, a range of photographs and pictures are available to support service users to make decisions about what meals or drinks they would like; clear descriptions of how service users communicate are within individual plans. A clear statement about who would advocate on a service user’s behalf was within individual records. Service users are supported to take reasonable risks and detailed risk assessments are in place describing actions to be taken to minimize identified risks. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 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): 12,13,14,15,16,17 Service users have good opportunities to participate in valued and appropriate activities both in the home and in the community on a regular basis. Good support is provided to enable service users to keep in touch with family and friends. Staff are good at supporting service users to be as independent as possible and make choices. The food is good at the home and service users are actively involved in the planning, shopping and preparation of food. EVIDENCE: A good range of leisure opportunities are provided to the service users both in the home and in the community. Records kept in respect of this are excellent as they provide staff with good information about how service users have spent their time. For example, a record is kept of which DVDs have been watched and whether or not a service user enjoyed the film, records of which newspapers or magazines have been read. These records assist staff in Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 12 ensuring that varied activities are offered and service users’ responses are noted. Service users are offered good opportunities to participate in community-based activities. The home has its own transport to support this. On the day of inspection, a service user had been Christmas shopping with a member of staff, and some service users were going out in the evening to a party. Through examination of records and discussion with service users and staff, it is clear that service users are well supported to maintain contact with family and friends. A service user said that her family visit her at the home on a regular basis. There are sufficient communal areas within the home for service users to receive visitors in private. Observation of care practice confirmed that service users’ rights are respected. Staff were observed to offer choices to service users and support service users to make decisions. Staff were observed to knock on bathroom and bedroom doors prior to entering. Some restrictions are placed upon service users in respect of accessing all areas of the home. A lock is fitted to the kitchen door. The nurse on duty explained that this is only kept locked if staff are busy supporting service users and the remaining service users are unsupervised in the lounge. The nurse on duty said that a risk assessment had been completed in respect of this practice. The nurse also explained that the automatic door closure on the kitchen door was not functioning properly and this had led to the kitchen door being kept closed and locked more than usual; this must be repaired. Menus examined showed that a varied and balanced diet is offered to service users. Service users choose meals that they enjoy for the menu using photographs and pictures if required and are supported to participate in food shopping. There was evidence in daily records that service users are supported to participate with preparation of meals or watch meals being prepared if they are unable to be actively involved. This is good practice. A service user said that she enjoyed the meals. Special diets are catered for and good records are kept in respect of this. It is recommended that the guidance for staff relating to a service user’s dietary requirements be removed from the front of the cupboard door in the kitchen, in order to protect his privacy. Nutritional screening is undertaken where necessary and reviewed regularly. Necessary weight monitoring of a service user has not been possible due to difficulties in accessing the required equipment at the day service. See standard 19. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 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 Healthcare and personal care is good at this home, however suitable arrangements need to be made to ensure an identified need for an individual is met. EVIDENCE: Staff were observed to offer personal support with sensitivity and discretion. Personal support plans contain excellent detail about service users’ preferences and routines. Since the last inspection, tracking has been installed in the lounge, bathroom and bedroom in order to meet the changing needs of a service user. Although staff have recently received training in movement and handling, training specific to the new hoisting equipment has not yet taken place and it is recommended that this be provided. See standard 32. There was evidence in service user records that healthcare needs are regularly assessed and addressed. Service users are supported to access a range of healthcare services, for example, GP, physiotherapy, speech and language therapist, chiropodist. There was evidence in the records that a service user whose health has deteriorated has his health monitored appropriately. Records in relation to this were excellent. Service users have up to date health action plans and ‘OK health checks’. It was noted that an identified need for a service user be weighed every two weeks had not taken place since June. The nurse on duty explained that specialist scales with hoisting equipment are Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 14 necessary and these are only available at the day centre, however the service user has not been well enough to attend. Suitable arrangements must be made to ensure that the service user’s needs are met. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 15 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): EVIDENCE: Not assessed on this occasion. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 16 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): EVIDENCE: Not assessed on this occasion. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 17 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 Training is needed in how to use the new hoisting equipment. EVIDENCE: Standard 32 was not assessed completely, however it is recommended that staff be provided with training in how to use the newly installed hoisting equipment. The nurse on duty explained that all staff had recently attended movement and handling training, however this had not covered the use of the equipment now installed in the home. The inspector did not fully assess standard 34, however the nurse on duty reported that the home does not hold all recruitment records for staff as these are kept centrally. The organisation is still in discussion with CSCI regarding this matter therefore the requirement made at the last inspection regarding this has been brought forward. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 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, 39, 41 The manager of this home is suitably qualified and competent. Service users benefit from a well run home. Satisfactory quality assurance and monitoring systems are in place at this home although a system for publishing the results needs to be developed. Record keeping at this home is excellent. EVIDENCE: The manager is registered with the Commission for Social Care Inspection. She is a qualified nurse having an RNMH qualification and also has an NVQ level 4 in management and NVQ assessors and internal verifiers award. The manager attends regular training in order to maintain and update her skills and knowledge. The findings of the inspection confirm that service users benefit from a well run home. Questionnaires are sent to service users and their relatives seeking their views about the quality of service offered. The manager was unsure if the results of the questionnaires were published or made available to service users or other Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 19 interested parties; a requirement has been made in respect of this. St Anne’s have attempted to organise meetings for families and advocates to discuss the services provided, however the manager reported that there has been little response. The home has an annual development plan that is available in the home. Following a requirement made at the last inspection regarding hot water temperatures being too low, water temperatures were checked and found to be at the recommended temperature. Record keeping at this home is of a high standard. Records required by regulation are up to date, clear and detailed. Staff should be commended in this area. Guidelines specific to an individual’s dietary requirements should be removed from the front of the kitchen cupboard in order to protect the service user’s privacy. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 X X X Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X X X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Smithies Moor Score 3 2 X X Standard No 37 38 39 40 41 42 43 Score 3 X 1 X 2 X X DS0000001096.V271183.R01.S.doc Version 5.0 Page 21 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 YA34 Regulation 19 Requirement Timescale for action 31/01/06 2 YA34 17(2) 3 YA39 24(2) The registered person has documentary evidence indicating that anyone employed by them or another person who is working at the home is fit to work there. Timescale 31/10/05 unmet. A record is kept in the home in 31/01/06 respect of each person employed, which contains all the information stipulated in Schedule 4(6) of the Care Homes Regulations 2001. These records are available for inspection. Timescale 31/10/05 unmet. The registered person must 20/02/06 make the results of service user/relatives surveys, in respect of quality of care provided, available to service users. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Good Practice Recommendations DS0000001096.V271183.R01.S.doc Version 5.0 Page 22 Smithies Moor 1 2 3 Standard YA19 YA32 YA10YA41 Suitable arrangements should be made for ensuring necessary equipment is available to weigh service users as necessary. Staff should be provided with training regarding newly installed hoisting equipment. The practice of displaying service user guidelines in respect of dietary requirements on the front of the kitchen cupboard should be reviewed. Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 Page 23 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 Smithies Moor DS0000001096.V271183.R01.S.doc Version 5.0 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. 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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