Care Home: 509 Leeds and Bradford Road

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What the care home does well The service is good at giving information to people in a wide variety of ways, so that they can understand in the best way for them. This might be by the use of sign language, photographs or clearly written information. They work well with people`s relatives and ensure that they have up-to-date information about the service and how to raise any concerns that arise, on behalf of individuals that may not be able to do this for themselves. The use of a person centred care planning system makes sure that each individual is involved in setting out their own wishes and goals and regularly reviewing how these are going with their key worker.The service is continually looking at ways in which it can improve further, for example, by training staff and raising awareness about individuals rights and abilities to make decisions for themselves, and improving staff communication skills with the deafblind people. The use of video analysis also enables staff to look at their own practice. The service is intensively staffed, to meet the needs of the people who currently live there. People clearly had a good rapport with the staff and those who were spoken to said they liked the people who look after them. What has improved since the last inspection? The manager has taken action to resolve all of the requirements identified at the last inspection and the majority of good practice recommendations. The manager has made the complaints policy more accessible to people`s relatives, by sending everyone a copy of the most recent version (March 2008). Person centred planning has improved, and risk assessments are now in place, both for the building and for individual activities. The stair lift has been installed to the first-floor, so that people have safer access. Three bedrooms, the bathrooms and the lounge have been redecorated, and the previous problem of ventilation in the laundry room is now resolved. What the care home could do better: Staff records could be improved, by recording in a more consistent way when Criminal Records Bureau checks have been carried out and what the disclosure number is (these details are currently held centrally and not at the home). The rear garden is currently not very accessible to those with mobility difficulties, so the new manager`s ideas about improving access should be of benefit to them. Alternative ways should continue to be explored, of finding an acceptable compromise for the person who will not sleep in their bed. CARE HOME ADULTS 18-65 Leeds and Bradford Road 509 Leeds and Bradford Road Bramley Leeds LS13 2AG Lead Inspector Stevie Allerton Key Unannounced Inspection 11th April 2008 2:00 Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Leeds and Bradford Road Address 509 Leeds and Bradford Road Bramley Leeds LS13 2AG 0113 2040018 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) www.sense.org.uk Sense, The National Deafblind and Rubella Association Care Home 5 Category(ies) of Learning disability (3), Learning disability over registration, with number 65 years of age (2), Mental disorder, excluding of places learning disability or dementia (3), Mental Disorder, excluding learning disability or dementia - over 65 years of age (2), Physical disability (1), Sensory impairment (3), Sensory Impairment over 65 years of age (2) Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th April 2007 Brief Description of the Service: Leeds and Bradford Road is a converted period property. It provides accommodation on three floors for up to five younger adults or older people of both genders, with multiple disabilities including sensory impairments. The house provides level access to the front of building. The rear is not accessible to people who have a physical disability. The garden is on two levels giving people who are physically disabled the opportunity to sit out and enjoy the garden in the good weather. A passenger lift and stair lift provide people with access to the ground and first floor. The people who use the service are provided with single rooms. Additionally, there is a large dining kitchen and lounge. Public transport is situated close by and there is parking available on road. The house is owned and managed by SENSE North, a voluntary national organisation that aims to provide housing and services to people with sensory needs. The Manager in post is Ciaran Wyer, who has applied for registration with CSCI. Current fees (April 2008) are from £1258.00 to £1722.00 per week. Key information about the service is contained within the Statement of Purpose and Service User Guide. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 3 star. This means the people who use this service experience excellent quality outcomes. This inspection was carried out without prior notification and was conducted by one inspector over the course of two visits. The first, on 11th April, was from 2.00 pm until 6.00 pm and the second visit, on 15th April, was from 2.00 pm until 6.30 pm. Before the visit, accumulated information about the home was reviewed. This included looking at any notified incidents or accidents and other information passed to CSCI since the last inspection. This information was used to plan this inspection visit. Unfortunately, the Annual Quality Assurance Assessment (AQAA) was requested too late for it to be completed and returned to CSCI prior to the site visit, so no surveys were able to be sent out in advance. Some staff surveys were left at the service, but none had been returned by the time of this report being written. Two people were case tracked, and other files were looked at. Case tracking is the method used to assess whether people who use services receive good quality care that meets their individual needs. Where appropriate, issues relating to the cultural and diverse needs of residents and staff were considered. Using this method, all twenty-one key standards from the Care Homes for Younger Adults National Minimum Standards, plus other standards relevant to the visit, were able to be assessed. We spent time with people living at the service and spoke to relevant members of the staff team who provide support to them. What the service does well: The service is good at giving information to people in a wide variety of ways, so that they can understand in the best way for them. This might be by the use of sign language, photographs or clearly written information. They work well with peoples relatives and ensure that they have up-to-date information about the service and how to raise any concerns that arise, on behalf of individuals that may not be able to do this for themselves. The use of a person centred care planning system makes sure that each individual is involved in setting out their own wishes and goals and regularly reviewing how these are going with their key worker. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 6 The service is continually looking at ways in which it can improve further, for example, by training staff and raising awareness about individuals rights and abilities to make decisions for themselves, and improving staff communication skills with the deafblind people. The use of video analysis also enables staff to look at their own practice. The service is intensively staffed, to meet the needs of the people who currently live there. People clearly had a good rapport with the staff and those who were spoken to said they liked the people who look after them. What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&3 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The initial assessment and the transition phase between someone’s previous care setting and this service is carefully managed, and some creative ways of giving information about the service to new people were seen. This ensures that the person knows that they will be coming to live at the service that is right for them, and that support can be tailored to meet their needs. EVIDENCE: There were four people in residence at the time of the visit, with one vacancy. We looked at the admission documents for the last person admitted, very recently. Referrals come via the Leeds Joint Care Management Team who have a block contract with the service. Not everyone who currently lives at the service is a deafblind person, but all need assistance with communication. The statement of purpose and service user guide were updated in 2008 and new copies sent out to families. The statement of purpose refers to equal access to activities regardless of the person’s impairment. Specially skilled communication is supplied, to minimise the effect of an individuals impairment. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 9 We discussed with the manager how the new person had been admitted. She was visited at her previous placement and staff took along photographs of the service in order to show her the available bedroom, the kitchen, staff members, etc. They were able to talk to her about the service and the people who live there before she came on her first visit. An information pack was put together for her. The AQAA states that training is to be provided for all staff in the Mental Capacity Act, to ensure that if someone is unable to make a decision for themselves the staff have the ability to make decisions in their best interests. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The person centred care planning encourages and enables each individual to set out their wishes and goals and develop their own lifestyles as they choose. People are supported to take risks as part of an independent lifestyle. The service has a clear vision of how they want to develop person centred planning, so that people can be empowered to make decisions about their own lives. EVIDENCE: Two people were case tracked; one was a new admission that the staff were getting to know. There was no detailed care plan in place yet for this person but some very good assessment information was in place. The service uses a person-centred care planning method, which is reviewed at six monthly intervals and peoples desires, wishes and targets are monitored by way of the monthly key worker meetings. At these meetings, the Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 11 individual’s care plans, weekly calendars and leisure activities are discussed with their key worker; they also look at what made them happy and sad over the past month. Personalised daily diaries are kept, participation in the daily routines of the house are recorded and changes made when necessary. Each of the people living at the service have their own personalised communication system, which can include objects of reference. Photographs are used in conjunction with the calendar system. All of the staff are learning British Sign Language (BSL). Risk assessments are carried out in accordance with the organisation’s PRAMS documents -- Person Centred Risk Analysis and Management System. These are carried out to cover a wide range of eventualities, the environment and behaviours which could put the person, the staff and people in the community at risk. One was looked at for a person who was at risk of choking. This was cross-referenced to an eating and drinking guidance document. This stated that the person needed one-to-one supervision at mealtimes, which was seen in practice later in the day. The AQAA stated that the team are constantly striving to improve and implement the person centred planning approach, and to improve their communication skills with the people who are deaf and/or blind, in order to empower them to make decisions about their lives. The AQAA also set out the teams plans for improvement in the next 12 months, to revise and introduce new Sense standards; this includes peoples rights to pursue a self-determined lifestyle. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People are helped to take part in valued and fulfilling activities which they enjoy. The daily routines of the house promote independence and individual choice. People enjoy the food. EVIDENCE: Food: Menus were seen - these showed varied and healthy food options. People eat with the staff around the kitchen table, and they are encouraged to help with clearing away after mealtimes by taking their plates into the washing-up area. All of those people who are deaf and/or blind were seen being supported at mealtimes and have risk assessments associated with this. Activities: It could be seen from the weekly planners that people take part in a wide variety of educational and leisure opportunities, including courses at Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 13 colleges. Educational opportunities are assessed and monitored by the education coordinator. Some people access daytime activities at Sense’s Resource Centre on the outskirts of Leeds. The service has its own vehicle that enables people to get out on trips or attend appointments. The person centred plans include a section called “My Life Now”, which covers aspects such as learning and aspirations. One person expresses a wish to go on an aeroplane, and staff are currently exploring ways that this can be achieved. The manager is keen to access more activities in the wider community, not necessarily those provided by Sense. Staff are currently looking at booking holidays with people, and said that a cottage holiday in Wensleydale last year was very successful. People also enjoy going out shopping with staff from the house. It was noticed that ladies had well manicured nails; the beautician visits regularly to do hand massage and nails. Each person has a morning and evening routine which provides them with structure and some consistency, so helping them to anticipate what is going to happen next and consequently promote their independence. People were spoken to during the site visits, and describe the activities they are involved in and what they enjoy doing, such as an art group, going shopping, etc. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Peoples physical and emotional health needs are met, and the person centred planning ensures that people receive personal support in the way they prefer. Medication is handled safely, so that people are properly supported to keep healthy. EVIDENCE: The Person Centred Risk Analysis and Management System documents were seen in use where people had particular health issues such as choking on food. Professional input had been sought from speech therapists and dieticians. Personal care plans now include the individual’s end of life wishes. Policies and procedures regarding personal and healthcare support were seen. These were very clear for staff; for example, the policy prohibiting staff from giving medical consent for people unable to do this, included extracts from the relevant legislation, for staff information. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 15 There was extensive written information regarding health support for individuals. Video analysis is used as a practice tool for staff, so they can support and guide people in the best possible way. Medication was looked at; this is stored in a locked cabinet in a locked cupboard, dispensed by the pharmacist in the Boots Monitored Dosage System. The procedure is that medication is to be administered by two trained members of staff each time, and two signatures are recorded on the charts. All staff have received training in administering medication. This is now linked to NVQ (National Vocational Qualification) level 3 and the Skills for Care standards. Everyone has a health record and health action plan, which describes to staff how people need supporting. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use the service experience excellent quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The willingness of the service to take action to improve the way that relatives and advocates can access the complaints policy, makes sure that people who are potentially vulnerable are protected. The quality of the information within this policy is very informative and clearly written, and promotes a positive attitude to complaints management. EVIDENCE: The service has introduced a new complaints procedure (or Resolving Issues Policy), which is simplified and makes clear to staff their responsibilities to support and empower people to access the complaints process. A letter was sent out to parents with a copy of the new policy attached. This is very much aimed at other people advocating on behalf of people who cannot do this for themselves. People can now log concerns on the organisations web site, and they will be handled the same as complaints made any other way. Staff records showed that everyone has undergone the relevant criminal records and other background checks. During discussions with staff, they confirmed that are aware of potential abuse issues through their knowledge of individuals. There is good attention to gender sensitive care where this is an issue. All staff receive adult protection training within the first three months of employment, and sexuality and relationships training is also provided. Staff are encouraged to share any issues of concern during supervision meetings and are formally encouraged to voice such issues. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 26, 28 & 30 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. People live in a homely and comfortable environment with good attention by staff to their overall safety around the house. The home is clean and hygienic. The new managers ideas about improving access to the rear garden will be of benefit to people whose mobility is not good. EVIDENCE: A tour of the premises was carried out, accompanied by the manager, and one of the people living there very kindly volunteered to show her room. All of the requirements made at the last inspection had been attended to. A chairlift is now in place to the first floor bedrooms, and the bathrooms, the lounge and three bedrooms have been redecorated. Two bedrooms were seen, both of which showed that people were encouraged to personalise their rooms as they wish. Discussion took place with the Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 18 manager regarding one person who has a fear of going to bed, and the alternatives that could be put in place given that the situation cannot be resolved. There was a possibility that a reclining chair could be used in place of the bed, to at least allow the person to relax and elevate their legs at night. General health and safety, fire safety, kitchen hygiene and general cleanliness is to a good standard. The AQAA confirmed that routine maintenance of systems within the house has been carried out. A full electrical check was carried out in March, but at the time of inspection no certificate had been issued. General risk assessments for the building are in place. Objects of reference are used to signpost people’s way around the house, for example, a computer disc hangs on the office door handle, and a wooden spoon on the kitchen doorframe. There is a very pleasant enclosed terraced garden to the rear, where vegetables and herbs are grown. Access could be better to the garden. There is not a lot of space in the lounge, so some of the people prefer to spend time around the kitchen table. The people spoken with said they liked the house, and the person who showed us a their room was very pleased with it. The support staff keep the home clean. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. Staff have a good level of awareness of the needs of the people they are supporting, by way of a good standard of training and by the written policies of the organisation. Training is focused on delivering improved outcomes for people living at the home. There are enough staff on duty to meet individuals’ needs, and potential staff are recruited carefully to make sure vulnerable people are protected. Greater attention could be given to how staff records are kept, so that the information that proves that these checks have been carried out is easier to find. EVIDENCE: The personnel file was seen for the last member of staff who was recruited. Some of the required documentation was present, but not all of it. The manager stated that personnel records were kept centrally, including the CRB/POVA checks and copies of the written references. There was a note in the records that the CRB check had been carried out and when, although this was difficult to find. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 20 There was evidence that the person had received a structured induction, and was being regularly supervised. Training records showed the range and variety of training staff can have access to; currently training in person centred awareness is being accessed. The staff rota shows that there is always a minimum of two people on each shift, and the gender balance of these staff members is carefully managed, in accordance with Sense’s gender sensitivity policy. During the night there is one person on night duty supported by another sleeping in on call. A copy of the staff handbook was seen, which contains policies and guidance about how to support people. Three members of staff were spoken to over the two visits as well as the manager. One was spoken to about the training she has been involved in over the five years she has worked there. She said: “training is fantastic”, and that it was a very good organisation to work for. She demonstrated a good level of knowledge about protecting vulnerable people and maintaining their dignity through the gender sensitivity policy. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41 & 42 People who use the service experience good quality outcomes in this area. We have made this judgment using a range of evidence, including a visit to the service. The manager’s clear understanding of the organisations values and priorities, and how to translate them into practice, is leading to an increased quality of life for people at the home. There is a strong ethos of providing person centred care and involving the people who live at the home in all aspects of how it is run. There is good attention to health and safety issues and record keeping, which protects people living at home. EVIDENCE: Action had been taken to address all the requirements from our last inspection (April 2007). An application has been put forward for the manager to become registered. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 22 The results from the last internal quality audit surveys were seen (these were done in July 2007); the surveys were sent out to relatives, service users, support staff and purchasers. The staff handbook contains clearly written policies and procedures of the organisation. The organisations regional office is at Robin Hood, between Leeds and Wakefield, where some records are kept. The records looked at at the home were all up to date. These included: Fire Safety records, Health and Safety records, Financial records, Staff records, Staff rotas, Accident records, Medication records and Minutes of staff meetings. Fire safety records showed that a new risk assessment for the building and fire evacuation plans had been drawn up, for both day and night time. Fire training for staff is carried out every six months. The Health and Safety records show that water temperatures were being checked on a regular basis. Financial records for service users were seen; no one is able to fully manage their own money. Bank accounts have been set up with two signatures, and there is a robust procedure for managing peoples money. The organisation holds the Investors in People award. The manager said he felt there were good opportunities to develop within the organisation, that it is open and forward thinking, and encourages a respectful working environment. All staff receive annual appraisals and supervision six weekly. There are also monthly staff meetings within the home. The home is putting a buddy/mentor system in place for new starters, so they can be met on the first day and the mentor will take the lead with their induction training. The AQAA states that as a team they provide a high-quality service which is developed around individuals’ wants, needs and aspirations; this enables them to have a meaningful life. Video analysis is used to support the staff’s practical skills and improve interaction and communication with the people living at the home. They plan to continue communication skills training for all staff working with deaf and/or blind people, and are also planning to provide challenging behaviour training. Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 4 3 4 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 4 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 3 27 X 28 2 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 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 4 4 3 X 3 X 3 3 3 3 X Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 YA26 Good Practice Recommendations An alternative way of providing somewhere to sleep should be looked at for the person who will not use their bed; this would ensure that their rights continue to be respected, whilst ensuring their health and well-being is maintained. Increasing access to the rear garden would give greater opportunity for people with mobility problems to enjoy this area of the home. Staff records kept in the home should include a more consistent way of recording when Criminal Records Bureau checks have been carried out; this is to provide evidence that staff have been recruited according to best practice, in a way that protects vulnerable people. 2 3 YA28 YA34 Leeds and Bradford Road DS0000062102.V364368.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North Eastern Region St Nicholas Building St Nicholas Street Newcastle Upon Tyne NE1 1NB National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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