Inspection on 13/02/07 for Southlees

This inspection was carried out on 13th February 2007.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southlees 07/03/06

Southlees 08/11/05

Southlees 08/02/05

Southlees 24/05/04

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 Southlees 84 Aldonley Almondbury Huddersfield West Yorkshire HD5 8SS Lead Inspector Bronwynn Bennett Unannounced Inspection 13th February 2007 10:00 Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Southlees Address 84 Aldonley Almondbury Huddersfield West Yorkshire HD5 8SS 01484 428366 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) Bridgewood Trust Limited Mrs Vicky Louise Taylor Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 7th March 2006 Brief Description of the Service: Southlees is a care home providing personal care and accommodation for six adults with learning disabilities. It is owned by the Bridgewood Trust, a voluntary organisation providing a range of services to adults with learning disabilities. The home is situated on a housing estate in the Almondbury area of Huddersfield, with a local shop and pub within walking distance of the home. There is a wider range of shops and community facilities within 5 minutes’ drive of the home. The home is close to a bus route. The property is a detached house in keeping with other local houses. Accommodation is on two floors. Service users have their own bedrooms. In addition to this, service users share a spacious lounge, dining room, kitchen, two bathrooms, two toilets and a utility room. There is also a bedroom for use by the member of staff undertaking sleeping in duties. There is a parking area and small garden to the front of the property and a large garden to the rear. French windows leading from the dining room into the back garden on to a patio area have recently been added to the accommodation. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced visit carried out by one inspector. The visit began at 10.00 am and finished at 3.00 pm. During this visit the inspector spoke to some service users, some of the staff and the home’s manager. The inspector read records of people’s care and staff records, looked at how medicines are given and looked at the accommodation available in the home. There were two service users at the home on the day of this visit. The home is registered for six service users. Before this visit the Commission for Social Care Inspection sent out questionnaires. Six questionnaires were sent to service users living at Southlees. None were returned. Surveys were sent to six service users’ relatives and six responses were received. A survey was received from a social worker. No GPs responded to the survey. Other information used as part of this inspection includes notifications from the home about illnesses, accidents and incidents. Before we visited the manager completed a pre inspection questionnaire. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: Service users have their needs assessed before they are admitted into the care home. Service users have a care plan where personal needs and goals are recorded. Service users are supported to take part in activities. People are supported to make their own decisions. Staff offer a good level of support to service users around health care issues. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 6 The home is comfortable and provides a relaxed and homely place for service users. The staff are properly trained. The home is well run by the manager. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Service users have their individual needs assessed prior to admission into the care home. EVIDENCE: The needs of the individual service user are assessed prior to admission into the care home. The manager discussed how the staff spend time with potential service users, their parents and relatives, to ensure that Southlees is the right place for them. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users’ assessed personal needs and goals are recorded in their plan of care. The support required by service users to make decisions and the risks taken as part of an individual lifestyle are recorded in care records. EVIDENCE: A service user spoken to during this visit said they are able to make decisions about what they do. A relative who responded to the survey said the home provides a caring homely environment. The care and support provided is of a very high standard. All the surveys received by the CSCI said they felt the care home always meets the needs of the service users. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 10 The care records for two service users were looked at. Generally, the information kept in these records is good. However, greater care is required to ensure the information is easy for staff to follow. For example, when changes are made in an individual care record, these should be made in such a way that is clear and easy for the reader to follow. All entries made into any service users’ record should be made in ink, signed in full and dated. Overall, the information contained in the care records is good and details who may be giving care to the individual and how often. Service users are consulted regarding their personal preferences and there was some good interaction noted between service users and staff throughout this visit. Risk assessments are carried out for any identified risks to the individual. However, the guidance given in the nutritional assessment for one individual had not been fully followed. This was discussed with the manager who agreed to take action in this matter. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users are supported to be part of the local community and take part in appropriate activities. Service users are supported to maintain relationships with family and friends. The service users’ rights and responsibilities are respected. Service users are offered a choice of food and a healthy diet. EVIDENCE: During this visit a service user had chosen to spend some of their time listening to music in their room. Another service user had chosen to watch some TV. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 12 One person spoken to said they can choose their own activities. They said they like to clean their room and help carry out some other domestic tasks in the home. All those who responded to the survey commented that the home always supports service users to live their chosen lifestyle. One relative commented that the home provides opportunities and activities to ensure service users are part of the community and have the opportunity to try new experiences. Service users are supported to take part in further educational activity such as access to the local college. Individual choice of activity ranges from day care, Gateway club, craft centre. Service users are part of the local community and enjoy trips out bowling, horse riding, swimming, and visiting the local pub and theatre. The individuals’ relationship with family and friends is supported. A professional who took part in the survey carried out by the CSCI said that the service works well in encouraging relatives to visit the home and be involved. A service user said their relatives can visit when they like and they are also supported by the staff to spend some time away from the home. The staff were observed treating individuals in a respectful and dignified manner throughout this visit. Service users are supported to spend time alone should they choose to do so. All service users are provided with a key to their own room. There is support from staff for individuals to clean their own room and other household tasks where appropriate. All service users take part in the planning of the home’s menu. The staff support service users to eat a well balanced and healthy diet. As well as menu planning service users assist in shopping for food and preparing snacks in the home. This was noted during this visit to the home. Where an individual requires support to eat their meal, this support was seen recorded in the care records kept by the home. During this visit the service users were asked what they would like to eat, and were eating their meal in a relaxed environment with the appropriate care and support being given by the staff. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 13 Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service users receive personal support in their preferred way and the individuals’ health care needs are met. Greater care is required to ensure the home’s medication policy and procedure protects the service users. EVIDENCE: During this visit, individuals were seen being supported in their chosen way. The staff were friendly and service users and the staff were noted to have a good working relationship. A service user spoken to said the staff who work at the home are good. The relatives who responded to the survey said they were always kept up to date with important issues affecting their relative. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 15 Service users receive the care and support they need in their preferred way and personal preferences for times to rising, retiring to bed and choices regarding bathing were seen in the care records. There was evidence in the care records that the service users are supported to access NHS healthcare facilities such as GP and occupational therapist. Information was given regarding a service user not being able to use the weighing scales currently available in the home. This needs to be addressed so that all individual healthcare needs can be fully met. The medication for two service users was checked. One medication was correct. A service user’s medication looked at held a stock of prescribed creams. Although the home has developed a protocol for “as required” medication, greater care is needed as not all the records looked at had been endorsed by the GP. There was a stock of creams for one individual but the guidance written for the use of these did not give sufficient detail of at what stage to use, or to what areas. In addition, where prescribed creams have not been used for many months, the responsible person should contact the GP to check that the treatment continues to be appropriate and safe. The supplying pharmacist should also be contacted to ascertain the quality of a cream when it has previously been opened and used. All prescribed medication, including creams kept by the home, should be recorded on the individuals’ MAR (Medication Administration Record) sheet. These good practice issues were discussed with the manager who agreed to seek advice in the matter. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, service users feel that their views are listened to and acted upon, and they are protected from abuse. EVIDENCE: All the respondents to the survey by the CSCI said that they knew how to make a complaint and the home had always responded appropriately if they had raised any concerns about service users’ care. The home has a complaints policy and procedure that is displayed in the home. However, the procedure is in need of updating to include the timescales for dealing with complaints. A record is kept of all issues raised including complaints. There have been no complaints made to the home since the last visit by the CSCI. All staff have received adult protection training and a member of staff spoken to was able to demonstrate a good understanding of the required actions that must be taken should there be any allegations of abuse. The personal money for three service users was checked and correct. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Generally, the service users live in a comfortable and safe environment. The home is clean and hygienic. EVIDENCE: As part of this visit, a tour of the premises was carried out and the home was noted to be clean and odour free. The lounge areas offer a comfortable and homely environment for the service users to enjoy. A service user showed the inspector their bedroom that had been decorated and personalised through their own choices. Service users have access to the equipment they require to maximise their independence such as the use of a wheelchair to enable one service user to go out. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 18 The manager said there are plans to replace the home’s kitchen and dining room carpet. Consideration is also being given to changing the downstairs bathroom in to a shower room. The bathrooms contained cotton towels for communal use. This is not good practice; these areas should contain antibacterial hand wash and paper towels in order to promote good infection control practices. The laundry facilities were seen and were clean and well organised. However, this area was not suitably equipped for hand washing. Laundry facilities should be equipped with a sink for hand washing, antibacterial hand wash and paper towels. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The staff work hard to support the service users. Staff are appropriately trained to meet the needs of service users. The home’s recruitment policy and procedure is sufficiently robust to protect the service users. EVIDENCE: The staff working at the home during this visit showed a good understanding of the service users’ individual care needs. All the respondents to the survey said they felt the care staff had the right skills and experience to care for service users properly and the staff considered the different needs of individuals living at Southlees. All staff receive induction training and the required mandatory training. Staff also receive training specific to the health and care needs of the service users. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 20 Four of the six staff have achieved NVQ level 2 and five staff have been successful in completing LDAF training. The records for two staff working in the home were audited and held the required information. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management arrangements ensure service users benefit from a home a well run home. Generally, the home is run in the best interests of the service users. The health, safety and welfare of the service users, and the staff, is generally promoted and protected. EVIDENCE: The registered manager of the home is Mrs Vicky Taylor. She has good experience of caring for the service user group and is currently working towards the Registered Managers Award. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 22 A member of staff spoken to during this visit said the manager has supported them. There is some quality monitoring carried out within the home and monthly visits carried out by a representative of the organisation. Service user and staff meetings take place and there is regular supervision of staff. The organisation is currently developing a service user questionnaire to further enhance its quality assurance systems. The fire records were checked and the home’s fire system and emergency lighting is tested weekly with the appropriate records being kept. In addition, the home carries out regular fire drills with the service users and the staff. There is a lack of information posted in the home regarding the routes to take in the event of a fire. This matter should be addressed and good practice advice was given to the manager at the time of this visit. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 4 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 2 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 3 X 3 X X 2 X Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? NO 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 YA30 Regulation 13.3 Timescale for action The registered person shall make 13/04/07 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. Facilities for hand washing must be sited in the laundry room. The registered person must 13/04/07 ensure that the fire safety procedures are displayed and in suitable formats for service users Requirement 2. YA42 23.4 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 YA6 Good Practice Recommendations Changes made in individual care records should be made in such a way that is clear and easy for the reader to follow. All entries made into any service user’s record should be made in ink, signed in full and dated. The actions required as part of an individual’s risk assessment should be fully followed to ensure healthcare needs are fully met. DS0000026328.V322450.R01.S.doc Version 5.2 Page 25 2. YA9 Southlees 3. 4. YA19 YA20 5. YA22 Suitable weighing scales should be purchased to ensure accurate records of an individual’s weight can be kept. There should be detailed information available to staff where prescribed creams are being applied to service users’ affected areas. When these creams have not been applied for sometime, permission should be sought from the individual’s GP and advice from the supplying chemist. The policy and procedure for dealing with concerns and complaints should be updated to include the timescales for dealing with complaints. Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Brighouse Area Team First Floor St Pauls House 23 Park Square Leeds LS1 2ND National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Southlees DS0000026328.V322450.R01.S.doc Version 5.2 Page 27 - 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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