Inspection on 20/12/07 for 167 Church Road

This is the latest available inspection report for this service, carried out on 20th December 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

167 Church Road 21/02/06

167 Church Road 16/10/05

167 Church Road 14/02/05

167 Church Road 06/07/04

167 Church Road 04/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 167 Church Road 167 Church Road St Annes Lancashire FY8 3TG Lead Inspector Phil McConnell Unannounced Inspection 20 December 2007 09:30 th 167 Church Road DS0000010060.V343891.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 167 Church Road DS0000010060.V343891.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. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 167 Church Road Address 167 Church Road St Annes Lancashire FY8 3TG 01253 782699 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) church.road@unitedresponse.org.uk None United Response Mr Stephen Turner Care Home 3 Category(ies) of Learning disability (2) registration, with number of places 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 25th May 2006 & Random Inspection 28th February 2007. Brief Description of the Service: 167 Church Road is a small care home for adults with learning disabilities, registered for three people, although only two people live at the home, which they have done for a number of years. The well-established national charitable organisation United Response is the registered provider. The home is a detached two-storey house with an excellent range of communal living space and good access to local services and amenities. The organisation provides a vehicle to enable individuals to take part in leisure activities and access amenities. The staff team provide support in all aspects of daily living according to assessed needs and as identified via the care planning process. Individuals are supported and encouraged to develop their independence and take part in all aspects of community living. The service adopts an active support approach, in a stable environment, which enhances opportunities for personal growth and development. The staff team are supported by an experienced management team and an organisation, which clearly values its employees, and the people they support. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Various information was gathered in order to assess the key standards that are identified in the National Minimum Standards for Care Homes for Younger Adults, including: the pre inspection questionnaire, (completed by the registered manager) and an unannounced inspection visit to the service on the 20th of December 2007. One of the service users, the registered manager and the homes team leader were present throughout the inspection visit. During the visit to the home both of the service users’ files were examined and all relevant documentation was in place. The staff files also contained all relevant information, which is required for inspection purposes. There was the opportunity to observe the support and care being provided to one of the service users. The home’s policies, procedures and all other documentation including health and safety files and certificates were examined. (See management section). A full tour of the home was also carried out. (See environment section). Overall the general organisation of files, care plans and staff documentation has improved since the last inspection. There has also been a marked improvement in the environmental standards within the home. (See last report). What the service does well: The organisation has taken seriously the issues that were raised in the previous report. They have satisfactorily and adequately dealt with each one. People continue to be supported and cared for in a professional, motivational and empowering manner. This is done by a committed staff team, which is trusted and respected by the service users. There is a good atmosphere in the home, with people appearing to enjoy living there. There is an ongoing commitment to improving and maintaining the standards within the home. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Have more rigid timescales for assessment and care plan reviews. This will help ensure that peoples’ changing needs are quickly identified and any necessary action is taken as soon as possible. Be proactive in maintaining the environmental improvements that have been made. This could be achieved by having a rolling décor/maintenance programme. The AQAA states “encourage the people we support to consider more varied activities and endeavour to have more success in encouraging healthier lifestyles”. To continue with the provision of the ‘Good to Great’ tools training that has been successfully provided in recent times. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 7 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. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 8 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 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 9 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. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Individuals’ needs are appropriately and satisfactorily assessed, helping to give the assurance that people are very well supported and cared for. EVIDENCE: There have been no recent admissions to the home; the present service users have lived at Church Road for a number of years. United Response has good systems and procedures in place, in the event of a new admission to the home. It is apparent that there is a good understanding of the pre admission process and there is an assurance that any potential new service user, being admitted to the home would have a full and thorough assessment carried out. The organisation uses a ‘Listen to me’ booklet, which helps to identify individual needs and preferences. Thereby, helping to demonstrate that an individuals needs would be adequately and appropriately identified before moving into the home. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 10 The AQAA states, “We plan services in an ‘individualised’, person centred manner and work in partnership with all relevant others, i.e. families, friends etc,”. Service users’ files were examined and they were found to contain documented evidence to show that assessments are being satisfactorily reviewed by the individual social workers. It was evident that the care planning system has also improved since the last inspection visit, helping to demonstrate that peoples assessed needs are regularly monitored and if peoples’ needs change then care plans are appropriately adjusted, in order to ensure that peoples’ needs will continue to be provided. The statement of purpose and the service users’ guide were observed during the inspection and found to be of a very good quality. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 11 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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are supported and empowered to make informed decisions and take assessed risks, which promote and enhance their independence. EVIDENCE: As already mentioned there is now evidence that peoples’ care plans are being regularly reviewed. The organisation uses a ‘working manual’ entitled ‘getting it right’, which promotes supporting people in a person centred way. Service users’ files were examined and they contained separate sections, including: Personal interaction and communication profile, my relationships / schedule of activities, medication profile and health contacts, finances, risk assessments and active support (monitoring ‘keeping track forms’). Overall they were thorough and detailed, containing good support information. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 12 In talking to one of the service users, it was apparent that people are empowered to make their own decisions and choices. It was obvious that this person continues to grow in confidence and independence and with the correct support and encouragement he has been able to participate in activities of his choice that had previously caused him anxiety. It was also apparent that this person was very relaxed, content and trusting of the staff present during the inspection. The AQAA states, “Support plans organise provision of support to ensure that needs and preferences are respected and risks are assessed in order to allow people to pursue preferred activities in a safe and considered manner”. In observation it was clear that service users are treated with respect, and dignity in an inclusive and empowering way. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 13 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, 14, 15 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. People are positively supported in participating in meaningful and appropriate activities, in order to provide stimulation, motivation and promote community presence and inclusion. EVIDENCE: The person centred care plans are concise and detailed giving, clear guidance and information about the various activities that individuals are involved in. During the inspection visit it was evident that people were individually involved in different activities and pursuits in the local community. There was also evidence that people are supported and encouraged to access meaningful leisure pursuits outside their own community including holidays and day trips of their own choice. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 14 People are supported to maintain appropriate contact with their families. It was apparent that a considerable amount of work has been carried out and is still ongoing, in order to help service users maintain contact with their relatives. The AQAA states, “learning logs and shift reports record evidence of activities taking place and contact with families”. Minutes of team meetings and weekly planners also show that regular activities are taking place. It was evident that community participation and community presence is positively and actively promoted, enabling people to maximise their independence, whilst also initiating self worth and wellbeing. In discussion with staff members and examination of records, it was apparent that much thought and planning goes into food menus. People are encouraged to be involved in the preparation and cooking of meals as much as possible. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 15 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 and 20. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Peoples’ health care needs are satisfactorily provided, with people being enabled and empowered to communicate their choices and wishes. EVIDENCE: The people who presently live at Church Road require some support with their personal care and this is carried out with their full agreement. The AQAA states, “Intimate and personal care requirements and specific health needs are identified and recorded with key workers being responsible for monitoring and reviewing” and “Each person we support has a medical profile and an intimate support plan that identity individual personal health and support needs”. There was an appropriate medication policy in the home and the medications were securely and correctly stored and administered, with medication charts being accurately recorded and up to date. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 16 All staff have received satisfactory training in the medication process. Since the last inspection visit the medication procedure has been reviewed and medication procedures are now a regular item on the team meeting agenda, helping to ensure that the staff are kept up to date and have a full understanding of the medication procedures. There was documentation with regular review dates listed for the review of medications with the GP, thereby ensuring that the service users are receiving the correct medication and dosage, with a clinical overview being maintained on a regular basis. The inspector was informed that the GP is familiar with the service users and will visit the home if service users are reluctant to visit the surgery for any reason, for example one person can get anxious and uncomfortable with too many people and likes to have space. There was documented evidence of some input from a health professional for a service user, in order to help the service user with one of their health care needs. There is a plan to review each person’s medical profile on a monthly basis and to initiate a Health Action Plan for each person. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 17 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 and 23. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Satisfactory policies and procedures are in place, helping to protect people from abuse and harm. EVIDENCE: There was a satisfactory complaints policy and procedure in place. The AQAA states, “United Response have a complaints procedure that is available in accessible form. The accessible complaints procedure is explained to the people we support and a copy is enclosed with the service users guide”. There was documented evidence to show that the organisation has appropriately dealt with some concerns that have been raised since the last inspection. Staff are trained in the safeguarding of adults and the team are required to familiarise themselves with the organisation’s ‘Prevention of Harm’ policy and the ‘No Secrets’ document, which is a government guidance publication. There was evidence to demonstrate that service users concerns or requests are genuinely listened to. The home contains relevant evidence that all members of staff have had criminal record bureau clearance checks carried out (CRB), helping to show that the organisation is committed to protecting the people in their care. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 18 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 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environmental standards are good, helping to ensure that people live and work in a safe and pleasant home. EVIDENCE: A tour of the home was carried out and it was found to be clean, well decorated, comfortable and homely. There is a fully equipped kitchen, which was clean and hygienic. The lounge and separate dining rooms were also well decorated, bright, fresh and airy. There were new good quality carpets throughout many areas of the home including the hall stairs and landing. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 19 There has also been an improvement in the exterior of the building, with wellmaintained front gardens, new fencing and the rear yard was tidy, with the outside toilet being clean, hygienic and functional. (Previous concern). The homes laundry facilities are adequate to suit the needs of the two service users. It is apparent that there has been considerable improvement in the environmental standards within the home since the last inspection visit. Overall the home is well decorated, comfortable, spacious, warm, and homely. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 20 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 and 35. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The quality of training that is provided, helps to demonstrate that the staff team are adequately qualified to care for and support vulnerable people. EVIDENCE: The staff files were examined and they provided relevant information, with regard to people’s knowledge, competency, skills and qualifications including, supervision notes, (supervisions have increased since that last inspection visit), evidence of training, with all staff either having achieved NVQ or in the process of completing the course (national vocational qualification). There was also evidence that regular staff team meetings are taking place, this is also an improvement since the last inspection. The homes/organisations policy and procedure for recruitment was thorough and satisfactory. There was relevant documentation available to clearly show that the correct process is carried out including, criminal record bureau checks (CRB), application forms and two satisfactory references. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 21 There is a structured and robust induction programme in place. All of these procedures help to demonstrate that the protection of vulnerable people is paramount, when recruiting new employees. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 22 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 and 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed and organised, helping to give the assurance that people are safe, with their welfare being promoted. EVIDENCE: The registered manager and the homes team leader were both present during the inspection visit. The registered manger has many years of experience and has obtained the NVQ in level 4 and has also achieved the registered managers award (RMA). The homes team leader is also very well qualified and experienced, having also achieved the RMA award. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 23 The previous inspection report highlighted that the home was not sufficiently well run or organised. It was clear at this present inspection that the home is now well-organised and well run, which benefits the service users and the staff team. The home has continued to maintain the ‘Investors in People’ award, which is a quality assurance-monitoring organisation. The organisation is positively demonstrating their own quality assurance monitoring. They have a programme of monthly and quarterly audits taking place, helping to ensure that the systems and procedures are monitored and reviewed appropriately. As previously mentioned there has been a marked improvement in the organisational side of the service and this is also evident with regards to the availability of health and safety inspection certificates. The gas, electric, portable appliance testing (PAT) and all relevant health and safety checks have and are being satisfactorily being carried out. Overall the health, safety and protection of people is now positively promoted, monitored and reviewed. 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 24 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 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 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 3 X 3 X 3 X X 3 X 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 25 NONE. 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. 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. Refer to Standard Good Practice Recommendations 167 Church Road DS0000010060.V343891.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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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