Inspection on 08/11/05 for Southlees

This inspection was carried out on 8th November 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 no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southlees 13/02/07

Southlees 07/03/06

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 8th November 2005 10:00 Southlees DS0000026328.V263380.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 Southlees DS0000026328.V263380.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. Southlees DS0000026328.V263380.R01.S.doc Version 5.0 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.V263380.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 8th February 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.V263380.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and was conducted over a 5.5 hour period. The inspector looked at all areas of the building, met with service users and staff and shared a meal with service users. The inspector also looked at records within the home. The inspector was also fortunate to meet with some relatives on this occasion, who were attending reviews at the time of this inspection. The inspector would like to thank service users and staff for their welcome on the day of inspection. What the service does well: What has improved since the last inspection? One member of staff has achieved an NVQ2 qualification. The majority of staff have received training in managing dementia. Southlees DS0000026328.V263380.R01.S.doc Version 5.0 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. Southlees DS0000026328.V263380.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 Southlees DS0000026328.V263380.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): These standards were not assessed, as the home has not received any new admission for some time. EVIDENCE: Southlees DS0000026328.V263380.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): 7,8 Service users are consulted about decisions in their lives and about how the home operates. EVIDENCE: Service users who spoke with the inspector explained that they have the opportunities to make decisions about their lives through the review process. Three service users had reviews on the day of this visit. Two said that they had been consulted in advance about the review and what they wanted to say. All seemed happy with the outcomes of the reviews and said they enjoyed participating. The manager holds residents’ meetings every 3 months. These are recorded and cover a wide range of topics, including views from service users’ about staffing, holidays and everyday running of the home such as cleaning. The evidence from these minutes suggests that these meetings are well attended and offer a good opportunity for participation of service users. In the last report it was recommended that meetings are held more frequently. This recommendation is repeated. Southlees DS0000026328.V263380.R01.S.doc Version 5.0 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 the following standard(s): 11,12,13,14,15,16,and 17 Service users have good opportunities for self-development and to adopt a lifestyle that suits them. Individual choices and rights are respected. Meals are healthy and nutritious. EVIDENCE: One of the important features of the lives of people living at Southlees, is their opportunities to follow their own interests and to develop their skills. For example one service user has a talent for art and has private lessons. Another is musical and attends a regular session to pursue this interest and has also been involved in teaching others. These are important activities that mean that service users are leading fulfilled lives. In addition service users are encouraged to take responsibility for aspects of caring for the home, by doing regular chores and to take pride in the environment. All service users are involved in daily activities most days of the week. Despite the fact that some service users’ abilities are being affected by age related illnesses, staff are working hard to maintain their activities and ensure that stimulating activities continue to be provided. Southlees DS0000026328.V263380.R01.S.doc Version 5.0 Page 11 Service users use local shops and community facilities and said that they enjoy activities such as shopping and going to the sports centre. The inspector was present at lunchtime. This was informal and service users had sandwiches and crisps in an informal way as they wished. The menus showed that the main meal is varied from day to day and includes vegetables at each meal. Service users indicated that they enjoy the food. There was evidence of good contact levels with families. Those relatives who visited on the day were clearly well known to staff and indicated that they visit fairly often. Some service users go to stay with their parents/relatives every weekend. It is positive that the home promotes this contact with families. Southlees DS0000026328.V263380.R01.S.doc Version 5.0 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): 20 Medication at the home is managed well. EVIDENCE: There is a medication policy and procedure, giving details of the way medications should be received, recorded, stored, handled, administered and disposed of None of the service users living at Southlees manage their own medication. The home operates the Boots monitored dose system. This was found to be working well. Medication is stored safely within the home and records were found to be properly completed and stocks of medicines such as paracetamol balanced. Southlees DS0000026328.V263380.R01.S.doc Version 5.0 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 the following standard(s): 22, 23 Complaints are managed satisfactorily within the service. There are satisfactory systems in place that protect service users from abuse and harm. EVIDENCE: The home operates the standard Bridgewood Trust complaints procedure. This is available in symbol format for service users as well as written format. Most service users would still require support to use this system however. No complaints have been made by service users, or their representatives, since the last inspection. There are clear systems in place to protect service users from abuse. Staff have received training in this as part of their induction and there are clear procedures for reporting abuse and whilstleblowing. Southlees DS0000026328.V263380.R01.S.doc Version 5.0 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 the following standard(s): 24, 26,29,and 30 The home is clean and tidy and well maintained. Bedrooms are suitable for service users but the locks need to be changed. The home environment needs to be reviewed as part of planning for the future needs of service users. EVIDENCE: The house was found to be clean warm and decorated in a fashion appropriate to the age of service users. There were photos of service users and artwork done by them displayed on the walls. Because of the changing needs of some service users some pictures had been temporarily removed so that glass in the frames can be replaced with safer plastic. There are other alterations that may be required that should be considered as part of planning for an ageing group of service users. The home’s manager has made a start on this process by involving other professionals such as an occupational therapist to assess bathing and toilet facilities. Forward planning is required however to ensure that service users are not left without adequate facilities when they can no longer use the current ones. The radiators, which are large old-fashioned metal types, should be considered for replacement as a Southlees DS0000026328.V263380.R01.S.doc Version 5.0 Page 15 potential hazard with the changing needs of service users, for example one person has reportedly had more falls recently. The inspector examined several bedrooms with the consent of service users. These were found to be homely and apparently decorated to suit the tastes of the occupants, who were very proud of their ‘space’. The inspector had one concern, which was around the locks on the bedroom doors, which were mortice type locks. None of the service users currently have a key and it was not clear if there are keys available to lock these doors. It is recommended that the locks are changed to single, single action locks so that service users may lock their rooms if they wish and be able to exit without the need for a key in an emergency. The home’s manager indicated that new locks are already on order and this is planned to be done in the near future. Southlees DS0000026328.V263380.R01.S.doc Version 5.0 Page 16 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 Staff have received training to equip them to provide appropriate care. All staff need to obtain NVQ2 qualifications, however. Staff recruitment procedures are generally good but improvements are needed to ensure that service users are protected at all times. EVIDENCE: The service users at Southlees have benefited from a very stable staff team in the past few years. All staff, except very new night staff, have completed basic courses provided through the Trust. Staff have also attended training in understanding dementia, which is relevant to this service user group. At the time of this inspection only two care staff had completed NVQ2 qualifications. All staff should ideally achieve this. As part of this inspection, staff recruitment files were examined. All were found to be in order except for the most recent recruit who had started work before adequate checks had been completed. No POVAFirst check or CRB disclosure had been received before the worker began work at the home. This is not acceptable practice and must not recur. A requirement is made in respect of this matter. Southlees DS0000026328.V263380.R01.S.doc Version 5.0 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 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): 42 Health and safety issues are treated seriously within the home. EVIDENCE: As part of this inspection, health and safety records were examined. These were found to be in good order generally. Fire records showed that systems are tested and fire training is provided to all staff. Gas and electrical test certificates were found to be up to date. The home recently had a health and safety inspection as part of its internal audits. This highlighted the need for window restrictors to be fitted to two bedroom windows. This should be done as a matter of urgency. Southlees DS0000026328.V263380.R01.S.doc Version 5.0 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 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X 3 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 X 1 X X 2 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 2 X 1 X X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Southlees Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X X X X 2 X DS0000026328.V263380.R01.S.doc Version 5.0 Page 19 NO 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 YA26YA42 Regulation 23(4) Requirement Timescale for action 30/11/05 2 YA34 19(1) The locks on doors must be replaced with a suitable type to protect the safety and privacy of service users. All staff must have been properly 08/11/05 vetted before working in the home with 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. 1 2 2 Refer to Standard YA8 YA24 YA29 Good Practice Recommendations Meetings involving service users to discuss issues relating to the running of the home should take place more frequently than quarterly. The replacement of the radiators in high-risk areas should be considered as part of future planning to meet the changing needs of service users. 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. Window restrictors should be fitted to the two bedrooms that have not got these. DS0000026328.V263380.R01.S.doc Version 5.0 Page 20 3 YA42 Southlees 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. 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