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Inspection on 09/01/06 for 386 Lower Broughton Road

Also see our care home review for 386 Lower Broughton Road for more information

This inspection was carried out on 9th January 2006.

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 found no outstanding requirements from the previous inspection report, but made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The home was very welcoming, friendly and had a relaxed atmosphere. The home had a good Service User Guide and a Statement of Purpose in place. The residents appeared happy and relaxed. The home was clean and appeared safe. The home encouraged regular contact between the residents and their relatives. The residents participated in several leisure activities. The paperwork kept at the home was good.

What has improved since the last inspection?

The handling and administration of medication had improved. The home continues to maintain good standards of care.

What the care home could do better:

The home must ensure that all staff receives protection of vulnerable adults training. The bathroom needed redecoration including other areas of the home. This had already been identified as an area needing improvement by the home.

CARE HOME ADULTS 18-65 386 Lower Broughton Road Salford Gtr Manchester M7 2HH Lead Inspector Richard Dankwa Unannounced Inspection 9th January 2006 12:00 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 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.V277056.R01.S.doc Version 5.1 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.V277056.R01.S.doc Version 5.1 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.V277056.R01.S.doc Version 5.1 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`. 5th October 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.V277056.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was conducted on 9 January 2006. The manager and most of the residents were present at the time of the inspection visit. Some of the staff members were also present. The majority of the staff and residents present were spoken to during the inspection. The areas recommended as needing improvement during the previous inspection had been met. Other areas needing improvement were identified during this inspection visit. This inspection only looked at specific standards so it should be read together with the previous report to gain a full picture of the service being provided by the home. What the service does well: What has improved since the last inspection? What they could do better: The home must ensure that all staff receives protection of vulnerable adults training. The bathroom needed redecoration including other areas of the home. This had already been identified as an area needing improvement by the home. 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 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. 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 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.V277056.R01.S.doc Version 5.1 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): 1 Prospective residents were given the essential information to assist them make a decision whether to use the services of the home. EVIDENCE: Prospective residents were issued with a Statement of Purpose and a Service User Guide. Pictures and images were used in these documents to help some of the residents to understand the contents of them. The Service User Guide and the Statement of purpose were regularly updated. 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 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): 9 and 10 The home supported the residents to take risks to maintain their independence. Information about the residents was kept in confidence. EVIDENCE: The residents were supported to take responsible risks. All the residents had detailed risk assessments in place that allowed the staff to support them to maintain their independence. The risk assessments were reviewed on a regular basis to meet the changing needs of the residents. The home had a policy to deal with confidential information regarding the residents. All staff were aware of this policy and adhere to it. All confidential information was kept secure in the office. The residents were able to access their records whenever they wanted. 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 Page 10 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): 11, 14 and 15 The residents had opportunities for personal development. The home continued to support the residents to engage in leisure activities. Residents were assisted in maintaining contact with families and friends. EVIDENCE: The residents had Individual Learning and Development Plans in place. Some of the residents attended a development centre that was run by the company (Pendleton Care Ltd). The home had a good planned programme of leisure activities that the residents engaged in. The home documented the activities each the resident participated in and ensured that the residents were physically and mentally stimulated at all times. The residents were actively supported to maintain contact with their relatives and friends. Most of the residents had regular contacts with their relatives and some went home for overnight stays. 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 Page 11 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): 21 There was a policy for supporting residents who were dying or had died. EVIDENCE: The home’s policy highlights the importance of the staff to manage the death of residents sensitively and in a dignifying way. Each resident had a plan in place that included details of those to contact in the event of their death. Individual plans did not include the Funeral Directors that should be contacted in the event of a resident’s death. Recommendation was made for the home to add this information to the individual plans. 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 Page 12 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): These outcomes were not looked at as they were fully met in the previous inspection. EVIDENCE: 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 Page 13 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27 and 29. Residents’ bedrooms promoted their independence and lifestyles. The toilets and bathrooms provided sufficient privacy and met the residents’ needs. There was specialist equipment to maximise residents’ independence. EVIDENCE: The residents had single bedrooms with adequate floor space. The bedrooms were generally in good condition however some needed redecoration. The bedrooms were personalised and had several personal belongings in them. There were sufficient toilets and bathrooms available for the residents to use. These rooms were lockable to maintain privacy and dignity of the residents. The bathroom however needed redecoration and this must be carried out. The home ensured that specialist equipment for individual residents were available to maximise their independence. A chair was bought for one resident to use when having a shower. 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 Page 14 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): 34 and 35. The home ensured that the right staff were employed to look after vulnerable people. This means that the residents were safeguarded by the robust recruitment practices of the home. The home provided training to the staff to enable them to do their work appropriately. EVIDENCE: The home had recruitment policies and procedures in place that were read and signed by all staff. All staff had a Criminal Records Bureau check (CRB) and a Protection of Vulnerable Adults check (POVA) before they started employment. Examination of staff files pointed out that the staff received mandatory training and other specialist training such as autism awareness and dealing with challenging behaviour. The staff received regular supervision. There was no evidence that the staff had received POVA training. All staff must receive POVA training to enable them support and protect the residents from harm or abuse. 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 Page 15 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, 40 and 41. The home was run well. The home monitors the quality of care being delivered by seeking the views of the residents and measuring it with the aims, objectives and the statement of purpose of the home. The records required for the protection of residents and the running of the home were maintained. EVIDENCE: The manager ran the home well. The manager received training to maintain and update his skills and knowledge. The home’s policies and procedures complied with current legislature. All staff were aware of these documents, which they had read and signed. The policies and procedures were also accessible to the residents. The residents had access to their records and all information held about them. The paperwork held at the home was secure, up to date and in good order. 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 Page 16 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 3 2 X 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 X 23 X ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 X 29 3 30 X STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 X 14 4 15 3 16 X 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X X 3 3 X X 3 3 X X 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 Page 17 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 YA24 Regulation 23 (2) Requirement Timescale for action 31/03/06 2 3 YA27 YA35 23 (2) 13 (6) The registered person must ensure that all areas of the home are well decorated. Resident’s rooms must be redecorated. The bathroom must be 28/02/06 redecorated. The registered person must 31/03/06 ensure that staff received training in POVA. 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 YA21 Good Practice Recommendations Individual care plans should include the Funeral Directors that may be contacted in the event of a resident’s death. 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 Page 18 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 © 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 386 Lower Broughton Road DS0000062672.V277056.R01.S.doc Version 5.1 Page 19 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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