Inspection on 10/10/06 for Templefields

This inspection was carried out on 10th October 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Templefields 22/09/09

Templefields 26/09/07

Templefields 09/01/06

Templefields 15/12/04

Templefields 08/07/04

Templefields 18/03/04

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 Templefields Templefields House Temple Road Dewsbury West Yorkshire WF13 3QE Lead Inspector Bronwynn Bennett Unannounced Inspection 10th October 2006 08:35 Templefields DS0000026311.V308854.R02.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 Templefields DS0000026311.V308854.R02.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. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Templefields Address Templefields House Temple Road Dewsbury West Yorkshire WF13 3QE 01924 461056 01924 461008 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) VALEO Limited Miss Donna McMahon Care Home 14 Category(ies) of Learning disability (13), Learning disability over registration, with number 65 years of age (1) of places Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th January 2006 Brief Description of the Service: Templefields is owned and managed by Valeo Ltd, a private company. It is a care home for 14 people with learning disabilities and associated challenging behaviours. Templefields is located on Temple Road, Dewsbury, off the main Huddersfield Road. The home is close to public transport links and Dewsbury with all its facilities is close by. The accommodation at Templefields is arranged in two buildings. The main house has ten places and the Coach House four places, although at present there is only one person living in the Coach House. The Coach House has been extended, to provide more spacious living accommodation, including a conservatory. All of the bedrooms in the home are single and each building has its own lounge, dining room, bathrooms, laundry and kitchen. There is also a hydrotherapy pool and aromatherapy room available on the same site. These services are used by other homes in the Valeo group. The provider informed the Commission for Social Care Inspection on 14.9.06 that the fees range from £1,057.53 to £1,802.35 per week. Templefields DS0000026311.V308854.R02.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 the inspector. The inspector arrived at the home at 8.35am and left at 4.00pm. During this visit the inspector spoke to some service users, some of the staff and the manager Ms Donna McMahon. The inspector read care records, audited a sample of medications, reviewed staff recruitment and training records, and carried out a tour of the home. In addition to this visit the Commission for Social Care Inspection sent twelve questionnaires to service users living at Templefields. Seven completed questionnaires were returned. There were twelve service users living at the home on the day of this visit. Surveys were sent to eleven service users relatives and five GPs. The inspector received responses from three relatives and two GP surveys. Other information used as part of this inspection process includes notifications from the home to the Commission for Social Care Inspection about illnesses, accidents and incidents at the home, copies of the monthly management visit reports produced by the care provider, and a pre inspection questionnaire completed by the manager. The inspector would like to thank everyone for their assistance during this inspection process. What the service does well: The individual needs and aspirations of potential service users are assessed prior to admission in to the home. The service users feel well cared for and supported by the staff at the home, and some positive comments were received from service users and their relatives regarding the standard of care provided. The interaction between service users and the staff is good and service users feel confident to speak with staff should they have any concerns or complaints. Care records are detailed, person-centred and reflect the service users choices and preferred lifestyle and service users are supported to take risks. Service users are offered a varied diet and the opportunity to participate menu planning, food preparation and shopping. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 6 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. Templefields DS0000026311.V308854.R02.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 Templefields DS0000026311.V308854.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2. The individual needs and aspirations of potential service users are assessed prior to admission in to the home. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The admissions process for potential service users was discussed with the manager and the inspector saw evidence of completed pre admission assessments for service users. Templefields DS0000026311.V308854.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 9. Service users know that their assessed and personal needs and goals are recorded in their care plan. Service users are supported to make decisions in their lives and are supported to take risks as part of an independent lifestyle. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The care records for three service users were audited during this visit to Templefields. The care records looked at were detailed; person-centred and reflected the individuals’ choices and lifestyle. The service users spoken to during this visit felt well cared for and supported by the staff team at the home. A relative who responded to the survey was very complimentary about the care their relative has received at Templefields stating that the staff are very helpful and caring. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 10 A discussion with a member of staff showed that where possible service users are involved in the formulation and review of their plan of care, however this was not evident in the care records audited. When a service user plan is formulated or reviewed the involvement of each individual should be recorded in the care records kept. Greater care is required in order to maintain care records, all of which should be signed and dated to ensure they are accurate and up to date. The daily records looked at did not give specific details of how a service user may have spent their day or if the care provided had met the requirements of the service users care plan. These issues were discussed with the manager. The choices and decisions made by service users were recorded in the care records audited. Service users manage their own finances with support from staff where needed. The surveys received indicate that service users are supported to make decisions about what they do each day. Three of the care records audited held up to date detailed risk assessments relating to any identified risks as part of the individual service users lifestyle. Templefields DS0000026311.V308854.R02.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16 and 17. 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 are respected and individuals’ choice and independence is promoted. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Service users are supported to take part in community activity and access further education and day centre facilities. There are no service users currently in employment however the manager said that service users are supported in this activity where appropriate. The service users preferred activities are recorded in the individuals care records. The staff provide flexible support for service users to follow their chosen lifestyle and activities. One service user commented that the staff are very helpful and supportive. On the day of this visit staff were taking some Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 12 service users out shopping and some service users had chosen to go out for tea. Service users family and personal relationships, and the support required to maintain those relationships are recorded in the individual care records. The interaction observed between the service users and the staff is good. The service users choice and rights are respected and are recorded in their individual plan of care. Some of the service users spoken with said that staff respect their right and need for privacy. Some service users are independent with their own menu planning, shopping and meal preparation. The support required for service users to undertake such tasks is recorded in their plan of care. The service users spoken with said that they are offered a choice of meals and can choose where to eat. The information given to the inspector prior to this visit shows there is a varied diet offered to service users. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 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 and 20. Service users receive personal support in their preferred way. Generally the health care needs of the service users are being met. The home’s medication policy and procedure does not sufficiently protect the service users. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The service users personal preferences for how to dress, their appearance, preferred times for rising and going to bed, bathing and their preference for taking meals are recorded in their plan of care. There was some good recording for service users preferences in personal care. The service users spoken with said that the staff are helpful and supportive and five of the surveys received from service users said that the staff always treat them well. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 14 All the care records audited had a healthcare record. There was evidence that the service users are supported to access healthcare services and facilities. The medication for three service users was checked. The medication dispensed from a “blister pack” system tallied with the records held. Medication prescribed on an “as required” basis could not be accounted for as medication administration records were not kept up to date. Some service users had “homely remedies” such as Paracetamol. The manager said that verbal consent had been obtained from the individual’s general practitioner to dispense Paracetamol, however this consent was not documented. All instructions relating to the dispensing of service users medication should be clearly recorded. The home has adopted the practice of pre dispensing some medication in preparation for a service user who may go out. This usually takes place at the beginning of medication month; this is not good practice. Such practice should only be carried out on a day to day needs led basis when required by the service user. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 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): 22 and 23. The service users feel that their views are listened to and acted upon, and they are protected from abuse. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home has a complaints policy and procedure that is in need of updating to include the timescale for handling complaints. There has been two complaints made to the home during the last twelve months that are now resolved. Six service users who responded to the survey said they knew who to speak to if they were not happy and the service users spoken to during this visit said they knew who to speak with should they have any concerns or complaints. Two relatives who responded to the survey said they were not aware of the homes complaints procedure. A discussion took place with the manager regarding the displaying of complaints policy and procedure. All the staff complete adult protection training as part of their induction training and the organisation has an ongoing programme of training that includes updates in adult protection. The staff spoken with during this visit had a good understanding of adult protection issues and the necessary actions that should be taken following any allegations of abuse. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 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): Generally the home is clean and hygienic but greater care is required to minimise the risk of cross infection. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: Five service users who responded to the survey said that the home is usually fresh and clean. A tour of the home was undertaken as part of this visit. The home was generally clean and odour free. The individual rooms looked at had been personalised by the service user. Service users no longer smoke in the home and instead are provided with a timber lodge within the grounds for this purpose. The manager said that regular audits are completed to address issues of maintenance, repair and redecoration of the premises. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 17 An anti slip mat in one bathroom was dirty, this poses a potential health and safety risk to service users. Communal sharing of such items is not acceptable as it presents a potential risk of cross infection. The homes laundry facilities were clean and well organised on the day of this visit. One of the laundry rooms is not fitted with a sink to provide facilities for hand washing and this must be addressed in order to meet infection control policy and procedure. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 18 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 and 35. Generally, a competent staff team supports service users. The home’s recruitment policy and procedure generally protects the service users but requires some minor improvement. Quality in the outcome area is good. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The information received by the Commission for Social Care Inspection prior to this visit states that six staff have completed NVQ (National Vocational Qualification) level 2 or above. In addition NVQ training is ongoing for a further eleven staff. Five of the service user surveys received said that the staff at the home always treat them well. The staff spoken with during this visit said that felt they received sufficient training relevant to their role. The records for three staff working at the home were audited. Generally these records were satisfactory but none of the records had a recent photograph of the individual. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 19 The inspector was advised that all staff receive induction training prior to working at the home, and that the organisation is to implement an ongoing staff training programme. There was some evidence of staff training in the staff records audited but generally the system of recording staffs ongoing training is not easy to follow or particularly well organised. The organisation should develop a system to record all the training undertaken by staff. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 20 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, and 42. The service users benefit from a well run home that is generally run in the best interests of the service users. The health, safety and welfare of the service users, and the staff, is not sufficiently promoted and protected. Quality in the outcome area is adequate. This judgement has been made from evidence gathered both during and before the visit to this service. EVIDENCE: The home has a registered manager Ms Donna McMahon. She is registered and is undertaking NVQ level 4 in management. The manager presently has the benefit of some administrative support this should allow her greater flexibility to complete her own training and development and management of the home. The manager said that there has been some quality monitoring and that surveys have been sent to service users relatives. There are some quality monitoring systems in place such as service user, staff meetings and quality Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 21 visits are undertaken by the organisation. In addition to these the organisation should ensure there is an effective quality monitoring system that seeks the views of service users, family and friends and any relevant professionals. The results of which should be published in suitable formats for service users and made public to any other interested parties. The health and safety records sampled were up to date. The fire records were checked. Fire testing is completed on a weekly basis and the manager said that fire drills are carried out on a regular basis. The emergency lighting was recorded as been completed every three weeks. Emergency lighting checks should be recorded on a weekly basis and daily visual checks undertaken. There are currently no procedures displayed in the home in relation to the actions and routes to take in the event of a fire. This was discussed with the acting manager and good practice advice given. The manager said that the fire safety work required by the fire authority has now been completed. There was no evidence available to show that all the staff had received fire training updates. All staff should receive fire training twice a year. There was no evidence available to show that all staff had completed food hygiene and infection control training. The information received prior to this visit states that seventeen staff has completed first aid training. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 22 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 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 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 3 2 X 3 X 2 X X 1 X Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 23 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 YA20 Regulation 13.2 Requirement The registered person must ensure that all medication not returned to the supplying pharmacy must be carried forward onto MAR sheet complete with the stock balance. Timescale for action 10/10/06 2. YA24 13.3 3. YA30 13.3 There must be a clear system in place when medication is taken out of the home by the staff for the potential needs of the service user. There must be no secondary dispensing that leaves medication out of original container for periods that it is not required. The registered person shall make 17/10/06 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. Non-slips mats must be kept clean and must not be used communally. The registered person shall make 30/11/06 suitable arrangements to prevent infection, toxic conditions and the spread of infection at the care home. Facilities for hand washing must DS0000026311.V308854.R02.S.doc Version 5.2 Page 24 Templefields 4. YA34 19.1(b) 6 be sited in the Coach House laundry room. The registered person shall not employ a person to work in the care home unless - they have obtained in respect of that person the information and documents specified in schedule 2 of the Care Homes Regulations 2001. There must be proof of a person’s identity including a recent photograph. The registered provider must ensure accurate and up to date records are kept relating to staff training and any other records required for the effective and efficient running of the home. 30/11/06 5. YA35 YA42 17 30/11/06 6. YA42 23.4 The registered person must 30/11/06 ensure that the fire safety procedures are displayed in suitable formats for service users and that all staff receives fire training as required. 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 All service users care records should be kept signed and updated to ensure they are in good order. In addition, where a service user or their representative are involved in care planning and review processes a record should be kept. The daily records kept for service users should reflect the content of the individuals care plan and whether or not outcomes of the care plan have been met for the service user. The complaints policy and procedure is in need of updating DS0000026311.V308854.R02.S.doc Version 5.2 Page 25 2. YA6 1. YA22 Templefields 2. 3. YA32 YA39 to include a timescale of 28 days. The staff at the home should continue working towards NVQ certification. The organisation should continue to develop quality assurance and quality monitoring systems. Templefields DS0000026311.V308854.R02.S.doc Version 5.2 Page 26 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 Templefields DS0000026311.V308854.R02.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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