Inspection on 07/03/06 for Southlees

This inspection was carried out on 7th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southlees 13/02/07

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 Cathy Howarth Unannounced Inspection 7 March 2006 10:00 th Southlees DS0000026328.V263387.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 Southlees DS0000026328.V263387.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. Southlees DS0000026328.V263387.R01.S.doc Version 5.1 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 Care Home 6 Category(ies) of Learning disability (6) registration, with number of places Southlees DS0000026328.V263387.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th November 2005 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 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.V263387.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a short notice inspection arranged to ensure the manager was available to look specifically at the progress made in implementing the new care planning system established by the Bridgewood Trust. The inspector concentrated therefore on looking at this and on following up on requirements and recommendations made at the last inspection. Service users returning from day placements met with the inspector for a short time. Overall the inspection was positive. Some progress has been made in implementing systems but further work has to be done. Good progress has been made in meeting the requirements from the last report. The inspector would like to thank service users and staff for their welcome and time during this visit. What the service does well: What has improved since the last inspection? What they could do better: Service users are involved in developing their new plans but more progress needs to be made. Written explanations of gaps in employment for new staff should be more detailed if they are to be meaningful and verifiable. Southlees DS0000026328.V263387.R01.S.doc Version 5.1 Page 6 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. Southlees DS0000026328.V263387.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 Southlees DS0000026328.V263387.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): This standard was not assessed as no one has moved into the home for some years. EVIDENCE: Southlees DS0000026328.V263387.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 and 9 Service users are involved in developing their new plans but more progress needs to be made. EVIDENCE: The Bridgewood Trust has recently developed a new care planning system and has been in the process of establishing it in all of the homes over the past few months. At Southlees a promising start has been made in completing the detailed assessment documents and some of the daily recording systems are functioning well giving a good picture of what is happening in service users’ lives. There was evidence that service users had been consulted about their plans, and one service user said that people had talked to them about things they like and what they like to do. There was evidence of service users being kept informed about this process in the minutes of the residents’ meetings also. The area that needs work now is in turning the assessments into service user plans that ensure people’s needs are fully met and can be monitored through Southlees DS0000026328.V263387.R01.S.doc Version 5.1 Page 10 the daily recordings. None of the service users currently have one of these plans and so the development of these must be a priority as is the risk assessments that go alongside these plans. Requirements are made in respect of this area. Southlees DS0000026328.V263387.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): These standards were no assessed on this visit. EVIDENCE: Southlees DS0000026328.V263387.R01.S.doc Version 5.1 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 the following standard(s): 18 and 19 Service users benefit from staff offering a good level of support around health issues. EVIDENCE: Personal support and healthcare are covered within the new care planning system. Despite the fact that service user plans are not in place, the inspector found that this is an area where outcomes for service users are good. Staff have a high level of awareness around the specific health issues of service users and are using the new recording systems for contacts with health professionals to provide detailed records of health appointments. There was evidence on the individual files of staff being proactive in getting assistance for service users from appropriate health professionals such as occupational therapists. This is an area where the home does well. At the time of this visit, one service user was in hospital and had been for about a week. Because of the particular needs of this person, staff were visiting several times daily to offer support and familiarity and to give the service user their meals. Other service users were also being supported to visit, which they said they enjoyed and staff said helped the person in hospital enormously. The inspector found new protocols in place for service users who require ‘as required’ medication, which give clear guidance about when and why it should Southlees DS0000026328.V263387.R01.S.doc Version 5.1 Page 13 be given. It is recommended, however that this is endorsed by the service user’s GP if possible to ensure that any directions have been clearly understood. Southlees DS0000026328.V263387.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): These standards were not assessed on this visit. EVIDENCE: Southlees DS0000026328.V263387.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): EVIDENCE: These standards were only assessed in as far as the recommendations and requirements from the last report were followed up. Since that time new locks have been fitted to the bedroom doors in line with safety procedures. Also window restrictors have been fitted to the bedrooms windows that did not have them. Recently the old style radiators that presented a hazard have been covered and pipework has been boxed in for safety. These improvements should help to ensure the safety of service users at Southlees. Southlees DS0000026328.V263387.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): 34 and 35 Staff are well trained in the basics of their job and have access to good opportunities for further training. Recruitment procedures are generally thorough but some improvements are needed in the interests of protecting service users. EVIDENCE: There are staff training records kept for each member of staff. All staff have access to the Bridgewood Trust’s training schedule. All staff have basic induction courses they are expected to attend within their first period of employment. One new member of staff was having her first day’s induction during the course of this inspection. The manager gave a good outline of the home’s functioning and covered the important issues for safety and well being of service users as part of this process. Although the staff member was recruited to work nights she was being rostered to work days for the first week in order to establish relationships with service users and the running ofd the home. This is good practice. Good progress is being made in terms of meeting targets for NVQ2. At the last inspection, there were some shortfalls in the recruitment procedures. On this visit all the documentation for the new member of staff Southlees DS0000026328.V263387.R01.S.doc Version 5.1 Page 17 was in place. One recommendation however was for the record of gaps in employment to be more meaningful and detailed. Southlees DS0000026328.V263387.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 and 39 There are good systems in place to monitor the quality of the service. The home is well run but the manager needs to be registered. EVIDENCE: The manager of Southlees has applied to be registered by the Commission for Social Care Inspection but this process has been delayed. The evidence from this and the last inspection shows that the manager has a good grip of all the systems and procedures and is able to lead the team effectively in the best interests of service users. There are systems in place to ensure the quality of the service is maintained and the Trust’s own procedures service to support the manager. There are regular monthly visits by the provider as required. In addition there are regular quality audits and health and safety audits to ensure that systems are working well and service users are safe. Southlees DS0000026328.V263387.R01.S.doc Version 5.1 Page 19 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 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 X 23 X ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 X X 1 X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 X 3 X X X X Southlees DS0000026328.V263387.R01.S.doc Version 5.1 Page 20 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. 2. Standard YA6 YA9 Regulation 15 13 Requirement Service user plans must be developed without delay for each individual living at the home. Risk assessments for each service user must be completed. Timescale for action 31/03/06 31/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA29 Good Practice Recommendations The manager should develop a plan to provide for adaptations that will become necessary for service users in the future and begin the process to ensure these things are in place in a timely manner. Protocols for the administration of ‘as required’ medication should be signed by the GP wherever possible. Details of gaps in employment records should be more detailed. 2. 3. YA20 YA34 Southlees DS0000026328.V263387.R01.S.doc Version 5.1 Page 21 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 Southlees DS0000026328.V263387.R01.S.doc Version 5.1 Page 22 - 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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