CARE HOME ADULTS 18-65
386 Lower Broughton Road Salford Gtr Manchester M7 2HH Lead Inspector
Joe Kenny Unannounced Inspection 5th October 2005 10:00 386 Lower Broughton Road DS0000062672.V255072.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 386 Lower Broughton Road DS0000062672.V255072.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. 386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service 386 Lower Broughton Road Address Salford Gtr Manchester M7 2HH 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) 0161 737 7339 Pendleton Care Ltd Mr John Thomas Russell Care Home 3 Category(ies) of Learning disability (3) registration, with number of places 386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. 3. 4. All service users are aged between 18 - 65 on admission and have a learning disability. The maximum number of service users accommodated shall be 3. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The staffing arrangements in the home must be maintained in line with the minimum levels set out in the guidelines for published by the Residential Forum in `Care Staffing Homes for Younger Adults`. 14th March 2005 Date of last inspection Brief Description of the Service: 386 Lower Broughton Road is a residential care home offering support to three adults . The home is registered to provide care to adults with learning disability and related autism. The home provides personal care and support to residents in all aspects of day-to-day life. The home is registered in the name of Pendleton Care Ltd, the responsible individual is Mr Hugh Davis. The home is managed by Mr John Russell. The property is a large semi-detached building set on ground and first floor level. The home is situated in a residential area of Salford and is within easy access to public services and other amenities. 386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This inspection was carried out unannounced and involved discussions with residents and staff about life in the home. A number of records and systems were inspected and a brief tour of the home was undertaken. Residents were observed to be directly involved in daily issues relating to the running of the home. Residents confirmed that they regularly accessed resources outside of the home for leisure, social and educational purposes. This was evident on the day, as resident prepared to go out and some returned from a swimming activity. The organisation continues to evidence that the need of residents are monitored and reviewed by support staff and the manager of the service, in consultation with residents. Documentation such as the homes Statement of Purpose and Service Users guide are reviewed and were up to date. Procedures relating to complaints were well established as were the guidelines and training on Adult Protection Procedures. The inspection only looked at a limited number of standards, so this report should be read together with the earlier report to get a full picture of how the home is meeting the needs of the residents living there. In the period since the last inspection the home had requested a variation to the number of residents accommodated in order to met the needs of a young adult, this was agreed as the resident would move to a purpose developed provision by the end of the year. What the service does well: The home evidenced a clear commitment to support residents to access community resources and to support residents to live as independently as possible in a residential setting. There was a strong emphasis on community integration and meaningful life experiences. Staff were skilled in meeting residents need and were observed to assist residents in daily living and social care activities. A review in the structure of the staff team had been completed in the period since the last inspection. 386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 6 The manager and staff were observed to consult with residents through out the inspection and residents were relaxed and interacted positively with staff. The care plans maintained by staff were informative and the content of each file was specific to the named individual. Information in the files was held confidential and residents are encouraged to assist in the development of their own plans of care. Care plans seen gave detailed information about promoting choice, independence and well–being. 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.
386 Lower Broughton Road DS0000062672.V255072.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 386 Lower Broughton Road DS0000062672.V255072.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 Prospective residents and their representative are provided with relevant information to assist them in matters relating to the service provided at the home. EVIDENCE: The home continues to support residents to live an independent life style which reflects their chosen preferences and goals. The home had received an application to accommodate a further resident on an interim basis and appropriate steps had been taken by the home to address the needs of the individual referred to the home. The process of admission included an assessment of the individuals needs and an evaluation of how those needs would be met as detailed in the individuals care plan. Residents confirmed that they are involved in the planning of their care and records viewed confirmed residents involvement. Staff were observed to support, residents to maintain and develop social and independent living skills. The procedures for admission to the home were followed in relation to the new resident moving into the home. 386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 and 8 Residents’ individual care plans reflected their assessed and changing needs and reflected the choices and preferences of residents. EVIDENCE: The files relating to residents continue to be informative and included the assessment of needs, strategies to support residents and outcomes of the support offered. Programmes of care were person centred and are drawn up in consultation with residents. One resident entered into conversation with the inspector and confirmed that issues relating to choice are respected by the home and by staff supporting her. The plan of support continues to be reviewed on a monthly basis by staff working in the home. The information from reviews continues to be shared with relatives and the placing authority. The review identifies any changes in care and intervention and sets out strategies to address these changes.
386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 10 The aims and objectives of support and intervention are to enable residents to maintain a close and involved link with their local community with out risk to them. The arrangements in house also ensure residents are involved in the day to day running of the home and contribution to decision making about things that were important to them. 386 Lower Broughton Road DS0000062672.V255072.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): 12,13,16 and 17 All resident are encouraged and supported to be involved in all aspects of daily living in the home and their local community. EVIDENCE: Programmes of activity are developed on a weekly basis and arrangements for staff support are also planned, in order to ensure agreed levels of support are available to residents. This was evident on individual residents weekly activity plan and from staff rotas. Life style plans are aimed at supporting residents to develop skills and interact with their local community. Residents confirmed that they were consulted about their chosen weekly activities, such as trips to cinema, trampolining swimming and accessed community resources such as, colleges, clubs, health centres and local parks. The home continues to have access to vehicles to support residents on trips out. The arrangements for managing use of the vehicle and fuel costs continue to be monitored by staff and relatives are kept informed of these arrangements.
386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 12 Residents are actively involved in shopping arrangements for the house and will accompany staff on such trips. In house residents have access to the kitchen area, to make drinks and with support from staff, are involved in the planning and preparation of meals. 386 Lower Broughton Road DS0000062672.V255072.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 and 20 The arrangements relating to personal and health care needs of residents are detailed in their care plan and regularly reviewed by staff. Medication procedures ensure resident’s medication is administered as prescribed. EVIDENCE: Staff supported and assisted residents in a respectful and professional manner. Residents confirmed that they received the levels of support required in all tasks. From observations on the day and from records examined it was evident that the promotion of residents’ independence was a strong feature of the way the home was managed. The health of the residents was well recorded and understood by the staff team. Records were kept about all health professional and GP involvement in the care of the resident. The homes internal review procedures ensure placing authorities and relatives are informed of the outcomes of such reviews. Development programmes are aimed at supporting staff when responding to personal health care needs. Training had been provide to staff in relation to Autism awareness, challenging behaviour and understanding learning disability. The residents were being supported by the staff team to complete
386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 14 their personal health action plan. Health care issues are monitored by staff, who are available to residents who required support when attending. The home does keep a record of medication received by the home. However, staff are advised to monitor records relating to medication to ensure an up to date record/balance of medication is maintained by the home. The home is also advised to ensure that the member of staff with responsibility for medication holds the key on their person when on duty. 386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 The homes complaints procedure is available to residents and relatives to raise concerns about the service. Procedures relating to protection of vulnerable adults protected residents from risk of abuse. EVIDENCE: Information relating to raising complaints about the service, is available to residents and relatives in the homes statement of purpose and in the residents own service user guide. No complaints had been received by the home or the Commission for Social Care Inspection. From talking with the staff team on duty they were aware of the issues of adult protection and the safeguards necessary to ensure the residents safety was not compromised. The manager confirmed that all staff had accessed and read Salford Local Authority guidelines in relation to Adult Protection procedures. The home had taken appropriate steps to refer incidents to the adult protection team. 386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 16 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 28 and 30 The residents lived in a homely, comfortable and safe environment EVIDENCE: The home was comfortable and had a pleasant relaxed atmosphere. The manager indicated that discussions would be held in relation to programmes of redecorating. In general all areas were well maintained and any proposals to redecorate would further enhance the general appearance of the home. A brief tour of the building was undertaken, rooms were personalised and reflected interests of each resident. Communal areas were bright clean and suitably furnished. Records relating to management of fire systems, water temperatures and any repairs required on the premises were examined and indicated that health and safety issues in the home were being appropriately managed. The portable appliance testing of electrical appliances in the home was due to be carried out in September and should be addressed. 386 Lower Broughton Road DS0000062672.V255072.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): 32,33,35 and 36 The staff team were highly motivated, skilled and competent in supporting the residents. Staffing levels ensures adequate support was available to residents. EVIDENCE: The staff team have been in post some time now and were particularly well skilled in supporting residents. This included support in personal, social and area of communication. The staff team were found to be highly motivated and staff confirmed that moral in the team was good. The arrangements for supporting residents in the home and in the adjoining home had been reviewed and staff confirmed that the interchange in staffing arrangements and movement of residents between both house had been very effective for resident and for the staff team. Nearly 50 of staff had an NVQ in care with other members working towards achieving the award. The rotas for the period covering the inspection, 3 to 9 September indicated that 259.5 day care hours were provided. A minimum of two staff are on duty each day and this level will increase depending on activities undertaken.
386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 18 The manager indicated that a review of the staff structure for the house had been undertaken. The home propose to recruit a co-ordinator and a senior to support the manager on supervision, development and training issues. The manager stated that he will periodically do a waking night duty to monitor the support and dependency levels of residents. The home provided an appropriate gender mix in the staff team. If agency staff are required to cover at the home, this arrangement is conducted through the organisations head office. Staff supplied by the agency have been included in the organisations training programmes on Autism Awareness. The manager confirmed that the supplying agency forwards confirmation that the member of staff has been CRB cleared. This confirmation is retained at the organisation office and it is recommend that a copy is provided to the home for its records. Staff confirmed they received regular supervision from their line manager and that the management style at the home was positive and open. The manager confirmed that structured supervision sessions are maintained in the home and he holds the relevant experience and qualifications to meet the requirements of his position. There were appropriate procedures in place in relation to support and supervision of the registered manager. 386 Lower Broughton Road DS0000062672.V255072.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): 37,39 and 42 The management and administration procedure in the home ensure the health safety and welfare of residents’ is promoted and protected. EVIDENCE: Procedures relating to management and maintenance of health and safety procedures are established and monitored through internal audits and completion of Regulation 26 visits by the responsible individual on a monthly basis to the home. Programmes of development and supervision of staff are well established and sustained by the home. Care planning and reviews of residents needs are regularly conducted by the home to ensure it meets its intended objectives for each resident. 386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 20 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 X X X Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 X X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X 3 X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 3 3 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
386 Lower Broughton Road Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000062672.V255072.R01.S.doc Version 5.0 Page 21 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. 1 2 Refer to Standard 20 20 Good Practice Recommendations The home is advised to monitor records relating to medication to ensure an up to date record/balance of medication is maintained by the home. The home is advised to ensure that the member of staff with responsibility for medication holds the key on their person when on duty. It is recommend that confirmation in relation to agency staff been CRB cleared, is held at the home. 3 34 386 Lower Broughton Road DS0000062672.V255072.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection CSCI, Local office 9th Floor Oakland House Talbot Road Manchester M16 0PQ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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