Inspection on 07/12/05 for Weaver Court

This inspection was carried out on 7th December 2005.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Weaver Court 19/11/08

Weaver Court 26/11/07

Weaver Court 09/01/07

Weaver Court 19/04/05

Weaver Court 09/11/04

Weaver Court 28/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Weaver Court Moorfield Place Idlecoft Road Idle Bradford BD10 9TL Lead Inspector Carol Haj-Najafi Unannounced Inspection 7th December 2005 10:15 Weaver Court DS0000046742.V255710.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 Weaver Court DS0000046742.V255710.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. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Weaver Court Address Moorfield Place Idlecoft Road Idle Bradford BD10 9TL 01274 615538 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) Bradford District NHS Care Trust Mrs Wendy Rushworth Care Home 22 Category(ies) of Dementia (1), Learning disability (22), Learning registration, with number disability over 65 years of age (1), Physical of places disability (22), Sensory impairment (2) Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. The place LD(E) is specifically for the named service user Date of last inspection 19th April 2005 Brief Description of the Service: Weaver Court is a Bradford District Care Trust home situated in the Idle Croft area of Bradford. The home is registered to provide personal care for up to 22 adults with learning disabilities. The home provides long-term and respite care. Accommodation is provided on two floors; there are 22 single bedrooms. Eight bedrooms are identified for respite users and fourteen bedrooms are for longterm service users. Communal lounges are located on both floors. There are five bath/shower rooms, some of which have hoisting facilities. An aqua sense room is also provided. The home has a catering kitchen and a domestic kitchen. All laundering is undertaken on the premises. Weaver Court has a large enclosed garden to the rear of the building. A large car parking area is located at the front of the building. Local shops and bus routes are within easy access.. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. One inspector carried out this unannounced inspection between 10.15am and 5.30pm. The purpose of the inspection was to ensure the home was operating and being managed to a satisfactory standard. I spoke to two residents, five staff and the registered manager. Service users living at the home have very complex needs, and discussions with the majority of service users are limited. The inspector observed interaction of service users with each other and with staff members. Records were inspected including care plans, assessments, maintenance records and staff records. Feedback was given to the registered manager at the end of the inspection. What the service does well: What has improved since the last inspection? Service users have more opportunities to go out and do more activities in the home. An activity organiser is starting work at the home soon, which will further improve the activities programme. All staff receive regular support and supervision. This gives staff an opportunity to put forward ideas about the home and develop personally. The menus have been reviewed and different meals have been introduced. These have all been based on service user preference. Better recording systems have also been introduced, therefore it is easier to monitor nutrition and variety. Weaver Court DS0000046742.V255710.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. Weaver Court DS0000046742.V255710.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 Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, & 4 The home has a good admission process for people that are moving into the home long term. EVIDENCE: One service user recently moved into the home and another service user was going through the introductory period. Records for the service user that has already moved into the home were looked at. The service user visited the home on several occasions and had stayed for meals and overnight. A lot of information about the service user’s needs had been obtained from different professionals, this included speech and language, occupational therapy and psychology. Staff at the home had completed care plans and risk assessments. Staff confirmed that they generally receive information before service users move into the home. They have opportunities to meet potential service users and speak to carers when they visit the home. Emergency admissions only occur occasionally, and generally service users have used the service previously. However, one service user who was admitted on an emergency basis the previous week had caused disruption to other service users living at the home. Issues with emergency admissions and Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 9 respite services should soon be resolved, more information is detailed later in the report under the environment section. Service users and the manager do not know how much the organisation charges for each placement. The manager has regularly tried to obtain this information from Bradford District Care Trust and Bradford social services but has been unsuccessful. The regulations clearly state this information must be available in the home. Service users or their representative and the manager have a right to access this information. A scale of charges from benefits claimed on behalf of service users has been made available to the home but this does not provide full details of the amount charged in respect of each service user. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 10 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): These standards were not looked at during this inspection. EVIDENCE: Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 14, 15, 16, & 17 Service users are happy living at Weaver Court. Activities provision has generally improved since the last inspection and further improvements are planned. Holiday preferences for service users should be included in the plan of care and arrangements for funding should be included in the service user guide. EVIDENCE: When asked ‘what the home does well’, all staff consistently responded with positive comments about the quality of care. Staff comments included, ‘there is a high standard of care, service users are happy, the quality of care is fantastic’. One service user did say the home was noisy. The manager explained that a service user had recently been getting distressed and was often quite vocal, this was being explored with health care professionals. The manager talked to the service user about the reasons for the increase in noise and reassured them. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 12 Another service user said they would like an increase in day care. A referral for additional day care had been forwarded to the relevant department. The service user was aware of this. Staff also talked about the range of activities that are provided. They generally felt there had been improvement in the frequency of community activities and were looking forward to a new activity organiser/driver starting work shortly, which they feel will further improvement activity provision. Activity records were available but these had not been filled in regularly, however, daily records did show that more regular activities were being provided. Six service users have been on holiday in the last few months, some service users go on holiday with their family, and others go on day trips. If it is not appropriate for service users to go on holiday, this should be formally assessed and recorded in their care plan. The cost of the holiday, which includes accommodation for staff is generally paid for by the service user. This information is not readily available. Staff and daily records confirmed that there was regular contact with service users’ families. Menus have been reviewed and these are based on service user choice. Those service users who are able to express preferences have had opportunities to put forward ideas for meals at service user meetings. The cook and staff have used their knowledge and experience to devise the menu. The menu is generally followed but any variations are recorded. Occasionally service users have takeaway meals. They choose which takeaway they want at the service user meeting, this is then bought the following evening. A listening device (baby monitor) was in the corridor outside service users’ bedrooms. The manager explained this was to alert staff to any service users that were disturbed during the night. People can listen to conversations through the monitor therefore privacy can be compromised. A formal assessment must be completed for each service user to assess the level of risk. If a monitor is required, clear guidance on the use of monitors should be formalised to make sure the privacy and dignity of service users is not compromised. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Service users benefit from a flexible service and receive good health care. EVIDENCE: Staff talked about providing a service that is tailored to meet individual need. They said bedtimes and times for getting up on a weekend are flexible. Service users’ likes and dislikes and preferences are recorded in their plan of care. Service users attend a health clinic which is specifically for people with learning disabilities. The health clinic provides dental, podiatry and psychology services. Keyworkers are responsible for coordinating health care appointments. The assistant manager monitors health care through reviews and supervision. Detailed records of health care appointments are maintained. Staff responsible for each shift also take responsibility for the administration of medication. They complete medication training before they can take on this role. At each handover medication records are looked at to make sure no errors are noted. Medication systems were well organised. Tablets were counted and records were looked at to ensure the right number of tablets had been administered. These were correct. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 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): 23 Service users cannot access information about the amount of savings that are held on their behalf, therefore they are not aware of how much money they have to spend. EVIDENCE: All staff attend adult protection training as part of their induction and foundation training. The manager was fully aware of when and how to report any allegations of abuse. The home maintains accurate and detailed financial records for monies that are held in the home. Up to date financial records are not available for savings that are held on behalf of service users. The manager has made several attempts to access this information but has not received confirmation of the amount of savings that are held. The majority of service users have savings but do not know the amount. This is unacceptable and has been raised at previous inspections. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 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): 24, 25, 26, 27, 28, 29 & 30 Different types of service are provided at the home but this has caused some problems for the people who live at the home. Bradford District Care Trust is taking action to address this. The home is clean and tidy but some decoration, furniture, carpets and curtains are shabby. Service users’ bedrooms are pleasant. EVIDENCE: The home provides long term, respite, and emergency placements. Issues have been raised about the mix of services provided at Weaver Court. Some respite/emergency users have high dependency needs, and can cause disruption to others in the home; staff time with long stay service users and levels of activity are sometimes affected. Bradford District Care Trust has taken steps to separate long stay and respite services. A new respite unit is currently being built in the Fagley area of Bradford and when this is finished all respite services will transfer to the new unit. This will result in a much better service provision for long stay and respite service users. Weaver Court is divided into two units. The ground floor, which accommodates sixteen service users, consists of fourteen long stay beds and Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 16 two respite beds. The first floor unit is a two bedded respite service for people with challenging behaviour. I looked around the home, which was very clean and tidy. The upstairs unit has recently been decorated, and it has some new furniture and flooring. The downstairs unit is in need of decorating and generally communal furniture and fabrics are shabby. Some carpets and furniture are stained and damaged. Wallpaper and paintwork is also damaged. The manager said the unit is being decorated and furniture and carpets are being replaced. This is due to start in January 2006. The bathroom, which is used most regularly by service users, has a high-low bath, overhead tracking and a shower trolley. It does not have a hand basin, therefore service users or staff cannot wash their hands. There are also plans to improve the laundry room, currently dirty and clean laundry is dealt with in the same area. The manager said this has been raised as an issue at recent environmental health visits, and the planned improvements will meet the recommendations that have been suggested. There have also been proposals to change a shower room into a sluice room. The manager was advised that the commission must be consulted before the use of any room is changed. Service users who live at the home all have their own bedroom. These rooms were individual and most rooms had pictures, ornaments, and had been made comfortable and personal to each service user. Several service users have specialist equipment they need. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 34 & 36 Staff have a good understanding of their roles and responsibilities, and receive clear direction from the management team. They are well supported. The recruitment process must be better co-ordinated to ensure unsuitable persons do not work at the home. New staff have a good induction when they start working at the home. EVIDENCE: Staff felt there has been a greater clarity of staff roles and responsibilities, which has led to a better understanding of each other’s duties. Staff have specific responsibilities within the home, which has resulted in necessary tasks being carried out properly. This includes keyworker duties, health and safety checks, and regular reviews of care plans. Staff said the current management team work well together and give the team encouragement and guidance, and this has improved team morale. One staff that recently started work at the home confirmed that they had undergone a thorough recruitment process and had received a planned induction, which included completing mandatory training sessions. Recruitment records for three staff that recently started work at the home were looked at. Application forms were generally filled in with sufficient detail but one form had a gap in the employment history. The manager said this had Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 18 been discussed at interview but it had not been recorded. Only one reference was available for two of the applicants, although the manager said they were available at central office, where all records are stored. Interview questions and responses from the candidates were available for all applicants. There was no evidence of criminal record checks (CRB) being carried for staff working in the home, although again the manager said the information would be available at central office, as they are responsible for coordinating checks. One new employee had started work in August but a CRB had not been obtained until the end of November. The manager did not know the check had not been carried out, and the worker had been working unsupervised with service users and had taken service users to appointments. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 19 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): 39, 41 & 42 Records and procedures are well organised and regularly updated, and good monitoring systems are in place to ensure health and safety checks are carried out regularly. There is an element of apprehension about future changes, these are being dealt with appropriately by the manager. EVIDENCE: Records and files have gradually been reorganised over the last eighteen months. The manager has successfully introduced a system that is easily accessible and well organised. All staff were familiar with the system and were able to readily access information. Staff raised concerns about future plans for the service. New partnership plans have recently been discussed with staff and this has caused anxiety for some staff working at the home. The manager was aware of the problems and had taken steps to alleviate some of the concerns. A meeting with senior managers Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 20 had taken place and a staff meeting to discuss the plans was being held the day after the inspection. Quality is monitored through different systems, which include service user reviews, monthly reports and monthly visits to make sure the home is running properly are carried out once a month. Service user meetings are held monthly, those who are able to make suggestions are encouraged. The assistant unit manager is responsible for coordinating staff supervision. Regular supervision is provided and staff said they felt supported by the manager and assistant manager. Various health and safety records were looked at. Monitoring systems are in place to ensure checks are carried out on a regular basis, and any follow up work is actioned. A gas safety certificate expired in September 2005. A gas engineer had visited the home in September 2005 but there was no evidence available in the home that confirmed what work had been carried out. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 3 X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score X X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 X 13 3 14 2 15 3 16 2 17 Standard No 31 32 33 34 35 36 Score 3 X 3 2 X 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Weaver Court Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score X X 3 X 3 3 X DS0000046742.V255710.R01.S.doc Version 5.0 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA1 Regulation 5 Requirement The registered provider must ensure information relating to the service charges is available to service users and the registered manager. (Timescales of 31/08/04 and 31/07/05 not met) The registered manager must review the use of the listening monitor. Formal risk assessments must be completed for individual service users. The registered provider must ensure service users have access to all relevant information relating to their finances and up to date financial records are maintained. (Timescales of 31/03/05 31/08/05 not met) The registered provider must complete maintenance works identified in the report The registered provider must ensure a thorough recruitment procedure is implemented and all information identified in schedule 2 is obtained before new employees start work. The registered provider must forward a copy of the gas safety DS0000046742.V255710.R01.S.doc Timescale for action 28/02/06 2 YA16 12 31/01/06 3. YA23 17 28/02/06 4. 5 YA24 YA34 23 18 31/03/06 31/03/06 6 YA42 13 31/01/06 Weaver Court Version 5.0 Page 23 certificate to the commission. 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. 3. Refer to Standard YA14 YA14 YA24 Good Practice Recommendations The registered provider should include funding arrangements for holidays in the service user guide. The registered manager should ensure service user’s holiday/outing preferences are recorded in their plan of care. The registered provider should separate respite and long stay service provision. Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 24 Commission for Social Care Inspection Aire House Town Street Rodley Leeds LS13 1HP 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 Weaver Court DS0000046742.V255710.R01.S.doc Version 5.0 Page 25 - 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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