Inspection on 21/07/08 for Liverpool Road (23)

This is the latest available inspection report for this service, carried out on 21st July 2008.

CSCI found this care home to be providing an Good service.

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

Liverpool Road (23) 09/03/07

Liverpool Road (23) 03/02/06

Liverpool Road (23) 28/10/05

Liverpool Road (23) 23/03/05

Liverpool Road (23) 23/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

Extracts from inspection reports are licensed from CQC, this page was updated on 08/11/2008.

CARE HOMES FOR OLDER PEOPLE Liverpool Road (23) 23 Liverpool Road Thornton Heath Croydon Surrey CR7 8LS Lead Inspector Jon Fry Key Unannounced Inspection 21st July 2008 10:35 X10015.doc Version 1.40 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 Liverpool Road (23) DS0000028100.V363941.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 Older People. 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. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Liverpool Road (23) Address 23 Liverpool Road Thornton Heath Croydon Surrey CR7 8LS 020 8653 5280 T/F 020 8653 5280 mrsdaphnemahoney@yahoo.co.uk 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) Mrs Daphne Mahoney Mrs Daphne Mahoney Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (0) of places Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered person may provide the following category of service only: Care home only - Code PC To service users of the following gender: Either Whose primary care needs on admission to the home are within the following categories: 2. Old age not falling within any other category - Code OP The maximum number of service users who can be accommodated is: 3 21st May 2007 Date of last inspection Brief Description of the Service: Beatitudes, 23 Liverpool Road, is located in a quiet residential area of Thornton Heath. The home is near to local shops and well placed for transport links. The service provides care and accommodation for up to three older people and operates very much as a small family home. People living there have a single bedroom and can access a lounge, dining area and garden. Current fees are approximately £410 per week. Liverpool Road (23) DS0000028100.V363941.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 2 stars. This means the people who use this service experience good quality outcomes. We spent two hours in the home and spoke to one person who lives at the home and the owner / manager. We looked at records and documents kept at the service including the care plan for the individual. The home sent us an annual quality assurance assessment (AQAA). This is a self-assessment that gave us information on how well outcomes are being met for people using the service. What the service does well: What has improved since the last inspection? What they could do better: The Health and Safety issue around fridge temperatures needs to be addressed to make sure that food is being stored correctly. Notifications must be made to the CSCI in the event of accidents, incidents or any other significant events. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 6 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. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Adequate information is provided to people about the home. People’s needs are assessed before they come to live at the service. This makes sure that the home is suitable for their needs. EVIDENCE: The user guide for the home contains satisfactory information about the home, facilities, services provided, the complaints procedure and any services that incur an extra cost. We have recommended that the complaints procedure be updated to include the new contact details for the CSCI in London. We saw that assessments had been completed for one person whose file we looked at. These included details of health and personal care needs as well as interests and hobbies. The owner said that they had tried to obtain more Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 9 personal information about this person’s background but the individual preferred not to share these. A Placement Agreement is in place between the home and the Local Authority. This gives details of the financial costs and agreed services to be provided by the home. The user guide also has details of the contract terms for the service. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Care plans contain good information to help make sure that people’s needs are met. Arrangements for the handling, storage and administration of medication are good. EVIDENCE: The care plan we looked at contained some good information about the individual’s needs and is kept under review and updated as necessary. The owner and staff are able to get to know the people living there very well as it is such a small home. We have recommended that the owner keeps looking at the care plans in order to develop them to be more individualised. The care plan confirmed that individual health needs are met. We saw that good records are kept of appointments and people’s weight monitored. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 11 Medication continues to be managed well. Good medication policies, procedures and practices are in place with items of medication appropriately stored and labelled. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People have the opportunity to take part in activities both in and outside of the home. The menu reflects the individual foods that people living there enjoy. EVIDENCE: People who live there are able to sit in the lounge and watch television, talk with staff and see visitors. One person currently living there goes to a day centre twice a week and records showed lots of visits by family and friends. The owner has developed an individual menu reflecting the cultural background of a person who lives there. This tries to balance the person’s meal preferences with their health needs. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The service has a complaints procedure for people to use. The policies for Safeguarding Adults are available and give staff guidance on actions to be taken. EVIDENCE: A copy of the complaints procedure is displayed in the lounge. The manager reported that records are kept of complaints with none recorded in the last year. We have not received any complaints about Liverpool Road since the last inspection in May 2007. As stated previously, we have recommended that the complaints procedure be updated to include updated contact details for the CSCI. This document could also be made available in large print for the people who live there. We saw that the owner and staff have completed training in Safeguarding vulnerable adults. The Local Authority procedures are available for staff to reference should they need to. Records we saw showed that Criminal Record Bureau (CRB) checks are completed for new staff before they start working at the service. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 24 and 26. People using the service experience adequate quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The environment is clean, comfortable and homely. The home is maintained, decorated and furnished to an adequate standard. EVIDENCE: We saw that people live in a clean, comfortable and homely environment. The lounge and dining area provides a pleasant area for people to use and there is also access to a garden area via the kitchen. The kitchen is still functional but looks in need of some updating. Individual bedrooms provide adequate homely accommodation for people who live there. The bathroom upstairs has a bath chair fitted to help people use it Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 15 more easily. The handrail in this bathroom has been repaired since the May 2007 inspection. All areas of the home were clean and free from offensive odour when we visited. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff members complete training to help them carry out their role. Staff recruitment practices help protect the people who live there. EVIDENCE: The owner continues to live at, and manage the home, and carries out the majority of shifts. The owner is a Registered General Nurse and has a Certificate in Management. The owner told us that two members of staff work part-time at the home and the rotas we looked at confirmed this. There is usually only one staff member on duty at any time due to the small size of the service. We looked at records for these two members of staff and they contained all necessary documentation including a Criminal Records Bureau (CRB) check. We looked at the training records and saw that staff have been able to attend courses in areas such as Fire Safety, Safeguarding Adults and Manual Handling. We recommend that the owner looks at accessing further training around activities, dementia and person centred care in order for the service to develop. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 37 and 38. People using the service experience good quality outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The manager has the knowledge and experience to run the home. Health and Safety issues are satisfactorily addressed. EVIDENCE: The owner is the registered manager for the service and is a qualified nurse with many years experience in the field. One of the main strengths of the service is its small size and homely feel. This means that the owner and staff can spend time with individuals to informally consult with them. We also saw that staff have a regular supervision meeting with the owner and this allows for discussion about their training and development. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 18 The owner told us they do not currently hold any money on behalf of people living there. We have made two Requirements in this report. We saw one instance where a notification should have been made to the CSCI about an event that happened in the service. The other issue is for the home to look at the fridge temperatures being recorded. These were recorded as rather high although the thermometer showed a much lower temperature when we were there. Health and Safety is generally well managed otherwise and we saw records for gas safety, electrical and hot water checks. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 2 2 Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 20 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard OP38 Regulation 13 (4) Timescale for action In order to ensure the health and 01/09/08 welfare of people living there, daily records must be kept to show that the fridge is operating between 1 and 8°C. Notifications must be made to 01/09/08 the CSCI with regard to any events listed under Regulation 37. Requirement 2. OP37 37 (1) 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 OP7 OP16 OP19 Good Practice Recommendations The owner should keep developing the care plans to be more person centred and include more of the individual’s background / life history. The complaints procedure should include the updated contact details for CSCI in London. It is recommended that the procedure be displayed in large print. It is recommended that the kitchen be renovated as and when funds become available. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 21 4. OP30 The owner should look at accessing further training around activities, dementia and person centred care. Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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. Extracts may not be used or reproduced without the express permission of CSCI Liverpool Road (23) DS0000028100.V363941.R01.S.doc Version 5.2 Page 23 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!