Inspection on 15/10/04 for Barnhill Road (11)

Care Homes For Adults (18 – 65)Barnhill Road (11)11 Barnhill Road Wavertree Liverpool Merseyside L15 5BEAnnounced Inspection15th October 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: • Promote improvement in social care • Inspect all social care - for adults and children - in the public, private and voluntary sectors • Publish annual reports to Parliament on the performance of social care and on the state of the social care market • Inspect and assess ‘Value for Money’ of council social services • Hold performance statistics on social care • Publish the ‘star ratings’ for council social services • Register and inspect services against national standards • Host the Children’s Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Barnhill Road (11) Address 11 Barnhill Road, Wavertree, Liverpool, Merseyside, L15 5BE Email address Tel No: 0151733 7646 Fax No: 9999Name of registered provider(s)/company (if applicable) Community Integrated Care Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 3Category(ies) of registration, with (number of places) Learning disability (3) Registration number F020000066 Date first registered 30th July 2002 Was the home registered under the Registered Homes Act 1984 as amended? Do additional conditions of registration apply ? Date of last inspectionDate of latest registration certificate 30th July 2002 YES NO 19/04/04 If Yes refer to Part CBarnhill Road (11)Page 1 Date of inspection visit Time of inspection visit Name of inspector Name of inspector Name of inspector 1 2 315th October 2004 01:00 pm Dave O`ConnorID Code079616Name of inspector 4 Name of specialist (e.g. Interpreter/Signer) (if applicable) Name of establishment representative at the time of inspectionJanet Sloane, managerBarnhill Road (11)Page 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspector’s Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Methods & Findings National Minimum Standards for Care Homes for Adults (18 – 65) 1. Choice of Home 2. Individual Needs and Choices 3. Lifestyle 4. Personal and Healthcare support 5. Concerns, Complaints and Protection 6. Environment 7. Staffing 8. Conduct and Management of the Home Part C: Part D: D.1. D.2. D.3. Compliance with Conditions ( if applicable) Provider’s Response Provider’s Comments Action Plan Provider’s AgreementBarnhill Road (11)Page 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the Commission for Social Care Inspection (CSCI) is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000 as amended. This document summarises the inspection findings of the CSCI in respect of Barnhill Road (11). The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Adults (18-65) published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the CSCI regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the Standards. The report will show the following: • Inspection methods used • Key findings and evidence • Overall ratings in relation to the standards • Compliance with the Regulations • Required actions on the part of the provider • Recommended good practice • Summary of the findings • Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The following inspection methods have been used in the production of this report. The report is based on the findings of the specified inspection dates.Barnhill Road (11)Page 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 11 Barnhill Road is registered with the CSCI to provide care for three adults under the category of learning disability (LD). The home is part of and is managed by Community Integrated Care. The home is situated in the Wavertree area of Liverpool. The home benefits from being part of a small residential area and is close to local amenities, bus and rail routes. The building is a bungalow and has been adapted over the years to meet the needs of the service users. Service users occupy single rooms and share communal bathroom, kitchen and lounge/dining room facilities. The home is accessible to wheelchair users; the accommodation provided is spacious and the home is well maintained and furnished to a high standard.Barnhill Road (11)Page 5 PART ASUMMARY OF INSPECTION FINDINGSInspector’s Summary (This is an overview of the inspector’s findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) During the inspection it was evident that all of the requirements from the previous inspection were met. As a result of this inspection four requirements and two recommendations were made. During the inspection the Home was measured against a range of the National Minimum Standards for younger adults. Sample documentation was inspected and a summary of the findings are as follows: Choice of home: Of the five standards, five were assessed and these met the standards. A detailed and informative statement of Purpose and Service User guide has been devised that meet the regulations. The current service users have been resident at the home for a number of years and it is evident that their ongoing needs are assessed and kept under review. Individual needs and choices Of the five standards, five were assessed and these met the standards. Service users have an up to date care plan in place that is very well detailed and regularly reviewed. Each service also has an up to date Essential Lifestyle Plan. It is evident that service users rights and participation are promoted and encouraged in accordance with their individual needs. Lifestyle Of the seven standards, six were assessed and these met the standards. Service users are encouraged to maintain community links through the provision of individual activity programmes that are used flexibly according to the service users needs. Service users enjoy a range of activities both inside and outside of the home. Service users independence is promoted and maximised where possible. Personal and healthcare support: Of the four standards, four were assessed and three met the standards. Service users personal and health care needs are met according to need. Staff have undertaken medication training. The home has appropriate storage facilities in relation to medication, although a couple of issues were identified in relation to medication that require attention. Complaints and protection: Of the two standards, two were assessed and these met the standards. The Home has a complaints procedure in place. No complaints have been logged in the home’s complaints book. The home has appropriate procedures in place in relation to adult protection. Arrangements should be made to ensure that staff receive adult protection training. Barnhill Road (11) Page 6 Environment: Of the seven standards, seven were assessed and six met the standards. On the day of the inspection the home was found to be well maintained, clean and mal odour free. The gardens are accessible for wheelchair users and are well maintained. The premises is suitable for its stated purpose. Since the last inspection the internal aspect of the home has been re decorated to a very good standard. Service users have single bedrooms that are furnished to a high standard. Staffing: Of the six standards, six were assessed and four met the standards. The home is meeting the minimum staffing levels as determined by the previous registering authority. Records indicate that appropriate recruitment procedures are followed. Staff receive induction and ongoing training, although an issue was identified in relation to staff receiving updated training where appropriate. Management and administration: Of the seven standards, six were assessed and four met the standards. At the time of the inspection the manager had been in post for approximately four weeks. Standards assessed during this inspection and records inspected, indicate that adequate records are kept in relation to the administration of the Home. Fire records are maintained including the servicing of the fire detection/protection equipment. An issue was identified in relation to an electrical test certificate. All but one of the staff group have undertaken first aid training.Barnhill Road (11)Page 7 Requirements from last Inspection visit fully actioned? If No please list belowYESSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard Required actions Timescale for actionAction is being taken by the Commission for Social Care Inspection to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).MET (YES/NO)Barnhill Road (11)Page 8 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001, and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Regulation Standard * Requirement Timescale for action The registered person must ensure that medication administration records are clear, any mistakes should have a single line through the entry with a signature, date and explanation as to why the signature has been crossed through. The registered person must ensure that the PRN medication guidance for each of the service users is demonstrably kept under review. The registered person should undertake a staff team training audit identifying updated training needs where appropriate. The registered person must ensure that where necessary an up to date electrical test is undertaken. If this test has already been undertaken a copy of the certificate should be forwarded to the CSCI.113YA2015/10/04213YA2015/11/04318YA3515/12/04423YA4215/12/04Barnhill Road (11)Page 9 RECOMMENDATIONS Identified below are areas addressed in the main body of the report which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s). The code in “Standard” is a cross-reference to the Standards described in full in the section “Inspection Findings”. No. Refer to Good Practice Recommendations Standard * 1 2 YA23 YA37 The registered person should make adequate arrangements to ensure that the staff team receive adult protection training. The registered person should make arrangements to ensure that the manager is enrolled to undertake NVQ level 4 in management and care.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. YA10 refers to Standard 10.Barnhill Road (11)Page 10 PART BINSPECTION METHODS & FINDINGSYES YES YES YES YES NO YES NO YES NO NO YES YES YES NO NO NO YES NO YES 0 0 0 NO YES YES YES 7 0 15/10/04 13.00 4The following inspection methods have been used in the production of this report Direct observation Indirect observation Sampling • Pre-inspection questionnaire • Records • Care plans / Care pathways • Meals • Activities • Other enter details here ‘Tracking’ care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting professionals survey / feedback Tour of premises Formal interviews Document reading Additional inspection information: Number of service users spoken to at time of inspection Number of relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the responsible individual seen CRB check for the manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total No. of care staff employed (excluding managers) Total No. of staff with nursing qualifications employed Date of inspection Time of inspection Duration of inspection (hrs)Barnhill Road (11)Page 11 The following pages summarise the key findings and evidence from this inspection, together with the CSCI assessment of the extent to which the National Minimum Standards for Adults (18-65) have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No Shortfalls) (Minor Shortfalls) (Major Shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. “X” is used where a percentage value or numerical value is not applicable.Barnhill Road (11)Page 12 Choice of HomeThe intended outcomes for the following set of standards are: • • • • • Prospective service users have the information they need to make an informed choice about where to live. Prospective service users’ individual aspirations and needs are assessed. Prospective service users know that the home they 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.Standard 1 (1.1 – 1.4) The registered person produces an up to date statement of purpose setting out the aims, objectives and philosophy of the home, its services and facilities and terms and conditions; and provides each service user with a service users guide to the home. The statement of purpose should clearly set out the physical environmental standards met by the home in relation to standards 24.2, 24.9, 25.3, 25.5, 27.2, 27.4 and 28.2; and a summary of this information should appear in the service users’ guide. X X Range of fees charged From To £ £ (per week) NO Any charges for extras If yes, please state what the extras are 3 Key findings/Evidence Standard met? The range of fees for individual residents is dependent upon the level of their assessed needs. The home has a company mission statement that includes Community Integrated Care’s (CIC) core values. The home also has a copy of CIC’s client charter and philosophy of care. A complaints procedure displayed near the front entrance provides details of how to contact the CSCI Area office. An informative statement of purpose and service users guide that meets this standard. These documents have been updated and amended where appropriate since the last inspection.Barnhill Road (11)Page 13 Standard 2 (2.1 – 2.8) New service users are admitted only on the basis of a full assessment undertaken by people competent to do so, involving the prospective service user, using an appropriate communication method and with an independent advocate as appropriate. 3 Key findings/Evidence Standard met? The current service users have been resident at the home since 1991 and thus no new service users have been admitted to the home. It is anticipated that a prospective service user would be admitted to the home following an assessment undertaken by a service manager and the home manager in consultation with any relevant professionals and family members. Each of the service users at the home had an up to date care plan following the home’s assessment of their needs. Risk assessments are in place specific to service users individual needs. Inspection of care files, indicate that documentary information is kept in to relation epilepsy, elimination and weight charts for service users. Standard 3 (3.1 - 3.10) The registered person can demonstrate the home’s capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 3 Key findings/Evidence Standard met? The current service users at the home are not from ethnic minority communities. It was evident during the inspection that service users changing needs are reviewed on an on going basis and specialist intervention appropriately sought when required. The Service users have individual communication needs and the staff group have built up an awareness of communicating effectively with them. The home has an advocacy policy that states that service users should be given the opportunity to be supported by a third party or an independent advocate. Since the last inspection there have been no significant changes to service users needs and this is reflected in individual care planning records.Standard 4 (4.1 - 4.5) The registered manager invites prospective service users to visit the home on an introductory basis before making a decision to move there, and unplanned admissions are avoided wherever possible. 3 Key findings/Evidence Standard met? The current service users have been resident at the home since 1991. It is anticipated that any prospective service user would have a phased introduction to the home according to their needs.Barnhill Road (11)Page 14 Standard 5 (5.1 - 5.5) The registered manager develops and agrees with each prospective service user a written and costed contract/statement of terms and conditions between the home and the service user. 3 Key findings/Evidence Standard met? The service user guide contains a blank standard form of contract and completed contracts in relation to service users are contained in individual care files. Each of the care files inspected contained a copy of the service users terms and conditions.Barnhill Road (11)Page 15 Individual Needs and ChoicesThe intended outcomes for the following set of standards are: • • • • • 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.Standard 6 (6.1 – 6.10) The registered manager develops and agrees with each service user an individual Plan which may include treatment and rehabilitation, describing the services and facilities to be provided by the home, and how these services will meet current and changing needs and aspirations and achieve goals. 4 Key findings/Evidence Standard met? All three service users care planning files were inspected during this inspection. These indicate that service users have an up to date care plan in place. Each service user also has a recently devised Essential Lifestyle Plan in place. Service users are not involved in their care planning due to their levels of understanding, although relatives are involved in the process according to their wishes. Care plans inspected continue to be well structured and contained very good detail in relation to the needs of the service user and how those needs are to be met. From individual care plans and essential lifestyle plans the inspector was able to track identified need and how that need is to be fully met by the staff team. The manager is responsible for the drawing up of service users care plans, however she also invites care staff as a developmental opportunity to be involved in the process. Records indicate that care plans are reviewed at least three monthly or more often if required. The staff maintain daily records that are concise and contain pertinent information regarding the specific needs of service users. Records are maintained of staff signatures indicating that they have read individual care planning documentation. Standard 7 (7.1 – 7.7) Staff respect service users’ right to make decisions, and that right is limited only through the assessment process, involving the service user, and as recorded in the individual Service User Plan. 3 Key findings/Evidence Standard met? Service user involvement is limited due to their levels of understanding. Service users have limited communication skills and staff utilise their knowledge of the service user’s behaviour and facial expressions to inform choice and decision making. The home has details of local advocacy services displayed near the front entrance and relatives have been provided with a copy of advocacy service details.Barnhill Road (11)Page 16 Standard 8 (8.1 – 8.5) The registered manager ensures that service users are offered opportunities to participate in the day to day running of the home and to contribute to the development and review of policies, procedures and services. 3 Key findings/Evidence Standard met? Due to service users needs, service users are not able to actively participate in the day to day running of the home. Service users are provided with opportunities to observe activities such as cooking, gardening and service users accompanying staff to purchase shopping items. Service users sit in on care planning and staff meetings although their actual involvement is minimal due to their levels of understanding. During the inspection it was evident that the service users are the focal point of staff activity. Staff were observed spending time with service users within the communal areas of the home. Standard 9 (9.1 – 9.4) Staff enable service users to take responsible risks, ensuring they have good information on which to base decisions, within the context of the service user’s individual Plan and of the home’s risk assessment and risk management strategies. 3 Key findings/Evidence Standard met? Service users have risk assessments in place according to their current needs and inspection of all of the care files indicates that risk assessments are in place in relation to the environment, daily activities, out and about and service users health. It is evident that risk assessments are reviewed regularly and staff sign to indicate that they have read the risk assessment. The home has an unexplained absences policy. Standard 10 (10.1 – 10.6). Staff respect information given by service users in confidence, and handle information about service users in accordance with the home’s written policies and procedures and the Data Protection Act 1998, and in the best interests of the service user. 3 Key findings/Evidence Standard met? The home has appropriate policies in place in relation to confidentiality. Service users records are stored securely.Barnhill Road (11)Page 17 LifestyleThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 11 (11.1 – 11.4) Staff enable service users to have opportunities to maintain and develop social, emotional, communication and independent living skills. 3 Key findings/Evidence Standard met? Service users are afforded the opportunity to maintain and develop social emotional and communication skills according to their needs and levels of capacity. Although service users capacity to be involved in learning practical life skills is limited due to their levels of understanding.Standard 12 (12.1 – 12.6) Staff help service users to find and keep appropriate jobs, continue their education or training, and / or take part in valued and fulfilling activities. 3 Key findings/Evidence Standard met? The home has devised an individual activities programme for the service users that is kept under review. The programme contains a variety of activities, which take place inside the home and out in the community. The current service users are fully supported in regarding matters relating to their finances and benefits. Due to service users levels of understanding they are not involved in education programmes.Barnhill Road (11)Page 18 Standard 13 (13.1 – 13.5) Staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. 3 Key findings/Evidence Standard met? The activity programme contains a variety of activities that take place inside the home and out in the community, although the programme is open to change and is used flexibly. The home is situated in the heart of a residential area and service users are afforded the opportunity to attend local facilities such as the local café, bowling and seasonal pantomimes. On the day of the inspection service users had just arrived back from their twice weekly visit to the multi sensory room. The staff group keep themselves updated of local amenities and attractions via local papers, the library, adverts and the service user’s relatives. Planned activities are discussed and agreed during team meetings. The home has the use of the homes minibus, although the local transport facilities are also used. The Inspector was informed that service users are on the electoral roll. Standard 14 (14.1 – 14.6) Staff ensure that service users have access to, and choose from a range of, appropriate leisure activities. 3 Key findings/Evidence Standard met? Service users receive an annual allowance for holidays, which can be utilised for a block holiday or weekend/day trips according to their wishes and needs. The inspector was informed that all three services have very recently enjoyed a five day break in Wales. Service users and their relatives are involved in the planning of holidays/ trips where appropriate. Refer also to standard 13. Standard 15 (15.1 – 15.5) Staff support service users to maintain family links and friendships inside and outside the home, subject to restrictions agreed in the individual Plan and Contract (subject to standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Service user’s family links are actively encouraged and facilitated by the staff at the home. The home has no restrictions in relation to sensible visiting times. Service users contact with relatives is contained in care planning documentation were appropriate.Barnhill Road (11)Page 19 Standard 16 (16.1 – 16.11) The daily routines and house rules promote independence, individual choice and freedom of movement, subject to restrictions agreed in the individual Plan and Contract (subject to Standards 2 and 6 if necessary). 3 Key findings/Evidence Standard met? Service users have unrestricted access to the home and front and rear gardens. Level access and ramps are provided where appropriate. On the day of the inspection staff were observed to spend time and interact with service users.Standard 17 (17.1 – 17.9) The registered person promotes service users’ health and wellbeing by ensuring the supply of nutritious, varied, balanced and attractively presented meals in a congenial setting and at flexible times. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Barnhill Road (11)Page 20 Personal and Healthcare SupportThe intended outcomes for the following set of standards are: • • • • 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.Standard 18 (18.1 – 18.11) Staff provide sensitive and flexible personal support and nursing care to maximise service users’ privacy, dignity, independence and control over their lives. 3 Key findings/Evidence Standard met? Service users are fully supported by the staff to ensure that their personal care needs are met. Personal care is provided in the privacy of the service users bedroom or W.C/bathroom where appropriate. Arrangements are in place to ensure that female staff provide personal care to female service users. Service users are limited in relation to expressing choice. The inspector was informed that each service user has a key worker who takes responsibility to choosing clothes etc. that reflects the person’s personality. Service users independence is encouraged and this is reflected in care plans. Standard 19 (19.1 – 19.5) The registered person ensures that the healthcare needs of service users are assessed and recognised and that procedures are in place to address them. No. of incidents where service users have been taken to Accident & Emergency during last 12 months No. of service users with pressure sores at the time of inspection (from information taken from care notes) 003 Key findings/Evidence Standard met? The home fully supports each service user in relation to their healthcare and arrangements are in place for service user’s to receive chiropody, dental and optical services, this was evidenced in information contained in care files. Each service user has a health care plan in place which provides very good reference information in relation to individual health care needs and details of the most recent health care appointments, visits. Each service user has an annual check up with their G.P. Specialist interventions are appropriately referred.Barnhill Road (11)Page 21 Standard 20 (20.1 – 20.14) The registered manager and staff encourage and support service users to retain, administer and control their own medication, within a risk management framework, and comply with the home’s policy and procedure for the receipt, recording, storage, handling, administration and disposal of medicines. 2 Key findings/Evidence Standard met? The home has written policies in relation to the medication and the home has a metal secure cabinet for the storage of medication. An information sheet for all prescribed medication is contained on individual files providing a useful source of reference for staff. Sample medication records (MAR) inspected contained signatures were medication has been administered. However, three signature entries had been scribbled out. The manager indicated that the entries had been crossed out due to a staff member incorrectly signing this particular MAR chart. The registered person must ensure that medication administration records are clear, any mistakes should have a single line through the entry with a signature, date and explanation as to why the signature has been crossed through. Each staff member has provided a specimen signature for the home’s files, for reference purposes. Care staff have undertaken medication training that was provided by a trainer of the organisation. Service users care files contain written guidance in relation to medication pre scribed as PRN including the use of rectal diazepam. This guidance is dated January 2002. The registered person must ensure that this guidance is demonstrably kept under review. Staff have received training in relation to the administration of rectal diazepam and suppositories and there are arrangements in place for the newly appointed manager and staff member to undertake this training. Standard 21 (21.1 – 21.8) The registered manager and staff deal with the ageing, illness and death of a service user with sensitivity and respect. 3 Key findings/Evidence Standard met? There are appropriate policies and procedures in place to ensure that this standard would be sensitively met.Barnhill Road (11)Page 22 Concerns, Complaints and ProtectionThe intended outcomes for the following set of standards are: • • Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm.Standard 22 (22.1 – 22.7) The registered person ensures that there is a clear and effective complaints procedure, which includes the stages of, and timescales for, the process and that service users know how and to whom to complain. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to CSCI Percentage of complaints responded to within 28 days 0 X X X X 0 X 3 Key findings/Evidence Standard met? The home maintains a complaints book, although no complaints were recorded. The home’s complaint procedure is displayed in the front hall. The procedure contains the required details on how to contact the CSCI. The procedure also indicates that complaints will be responded to within 28 days.Barnhill Road (11)Page 23 Standard 23 (23.1 – 23. 6) The registered person ensures that service users are safeguarded from physical, financial or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, or inhuman or degrading treatment, through deliberate intent, negligence or ignorance, in accordance with written policy. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the DOH Guidance No Secrets No of staff referred for inclusion on POCA/POVA lists YES03 Key findings/Evidence Standard met? The home has a copy of the Liverpool City Council policy and procedures in relation to adult protection. The home has a copy of the organisations whistle blowing procedure that includes contacting the CSCI within 24 hours. Sample records in relation to service users personal finances were found to be satisfactory. Discussions with staff on duty indicate that the recently appointed manager and the staff team have not undertaken previous training in relation to adult protection. The registered person should make adequate arrangements to ensure that the staff team receive adult protection training. Care staff that spoke with the inspector were aware of the home’s whistle blowing procedures.Barnhill Road (11)Page 24 EnvironmentThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 24 (24.1 – 24.13) The home’s premises are suitable for its stated purpose; accessible, safe and well maintained; meet service users’ individual and collective needs in a comfortable and homely way; and have been designed with reference to relevant guidance. 3 Key findings/Evidence Standard met? Upon inspection of the premises, the home was observed to be well presented and maintained. The home is owned by a housing association and it is the responsibility of the housing association to undertake any routine maintenance. The home is situated in a quite cul de sac position and the front and rear garden areas are well maintained. Since the last inspection the majority of the internal aspect of the home has been has been re decorated throughout. The home provides a very well presented and homely living accommodation. The manager informed the inspector that there are plans to replace curtains in the bedrooms and lounges.Barnhill Road (11)Page 25 Standard 25 (25.1 – 25. 11) The registered person provides each service user with a bedroom, which has useable floor space sufficient to meet individual needs and lifestyles. Total no. of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1st April 2003) – single bedrooms below 10 sq.m usable space or additional compensatory space Total no. of wheelchair users accommodated for in rooms at least 12 sq.m Total no. of wheelchair users accommodated for in rooms less than 12 sq.m Total no. of shared rooms at least 16 sq.m Total no. of shared rooms below 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total no. of single bedrooms Number of single bedrooms with en suite Total no. of double bedrooms Number of double rooms with en suite YES NO NO 3 0 0 0 2 11 0 0 02 Key findings/Evidence Standard met? All of the service users accommodate single bedrooms, however measurements forwarded to the Inspector indicates that one room is below 9.3 sq m and two bedrooms exceed 12 sq m. Currently all of the service users use a wheelchair to varying degrees.Barnhill Road (11)Page 26 Standard 26 (26.1 – 26.4) The registered person provides each service user with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. 3 Key findings/Evidence Standard met? Service users bedrooms are individually decorated and furnished to a high standard. Since the last inspection all of the bedrooms have been re decorated. None of the three bedrooms has a hand wash facility, although the inspector is informed that the use of a hand wash facility would not provide any additional benefit for the service user. Lighting in bedrooms is provided that meets the service users needs. Each of the service users has a bedroom door that has an over-rideable lockable facility.Standard 27 (27.1 – 27.6) The registered person provides service users with toilet and bathroom facilities which meet their assessed needs and offer sufficient personal privacy. 3 Key findings/Evidence Standard met? The home provides toilet and assisted bathing facilities that meet service users current needs. The toilet and bathroom has an over rideable lockable facility.Standard 28 (28.1 – 28.3) A range of comfortable, safe and fully accessible shared spaces is provided both for shared activities and for private use. 3 Key findings/Evidence Standard met? Measurements forwarded to the inspector indicates that the home provides 10.2 sq m communal space for each service user. The laundry and kitchen are domestic in scale. Staff are provided with adequate facilities including a place to store personal belongings.Barnhill Road (11)Page 27 Standard 29 ( 29.1 – 29.8) The registered person ensures the provision of environmental adaptations and disability equipment necessary to meet the home’s stated purpose and the individually assessed needs of all service users. 3 Key findings/Evidence Standard met? The home provides a hoist to assist in the transfer of service users when necessary. All of the service users use the assistance of wheelchairs to varying degrees. It is evident that the home meets service users needs in relation to adaptations, in accordance with the home’s stated purpose.Standard 30 (30.1 – 30.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection, in accordance with relevant legislation, published professional guidance and the purpose of the home. 3 Key findings/Evidence Standard met? The home provides domestic style programmable laundry facilities that are situated in the garage. The garage floor has previously been levelled using a self levelling compound. The flooring has also been treated to ensure that it is impermeable. The W.C. water outlet is fitted with a temperature control device. Clinical waste is stored in clinical waste bags and stored inside a clinical waste bin until collected by the clinical waste contractor. The home has copies of corporate policies and procedures in relation to control of infection.Barnhill Road (11)Page 28 StaffingThe intended outcomes for the following set of standards are: • • • • • • 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.Standard 31 (31.1 – 31.7) The registered manager ensures that staff have clearly defined job descriptions and understand their own and other’s roles and responsibilities. 3 Key findings/Evidence Standard met? Staff members receive a job description as part of their induction process and staff that spoke with the inspector where aware of their role and responsibilities. Through discussions with the staff on the day of the inspection it is apparent that they are aware of service users individual needs. Copies of the GSCC code of conduct that are available for staff to read.Standard 32 (32.1 – 32.6) Staff have the competencies and qualities required to meet service users’ needs and achieve Sector Skills Council workforce strategy targets within the required timescales. 2 Key findings/Evidence Standard met? Information provided on the day of the inspection indicates that of the seven care staff one staff member has achieved NVQ level 2 and a number of other staff are currently undertaking the training. There are currently two staff members undertaking General Nurse training. In order for this standard to be fully met 50 of the staff team should have achieved NVQ level 2 by 2005. Staff skills and experience is assessed during the recruitment and appointment processes. Care staff on duty that spoke with the inspector were aware of service users individual needs and how those needs are to be met.Barnhill Road (11)Page 29 Standard 33 (33.1 – 33.11) The home has an effective staff team with sufficient numbers and complementary skills to support service users’ assessed needs at all times. Staff numbers/hours relating to the needs of service users are based on guidance recommended by the Department of Health. Personal Care No. service users High needs No. service users Medium needs No. service users Low needs Total no. of hours needed No. of staff with NVQ level 2 or above No. of Trainees registered on Sector Skills Council training programme X X X X 1 No. of full time equivalent Staff with nursing qualification (where applicable) No. staff hours allocated No. staff hours allocated No. staff hours allocated Total Hours Provided X X X X Nursing X X X003 Key findings/Evidence Standard met? The majority of the above information was not provided during this inspection. Sample inspection of the staff rota indicates that the home meets the staffing levels as determined by the previous registering authority. The inspector was informed that the home currently has two staff vacancies. The existing staff group and/or bank staff, who are familiar with the service users, are used to cover shifts where necessary. Regular staff meetings are held were issues in relation to the service users needs and staff roles and responsibilities are discussed. Standard 34 (34.1 - 34. 8) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 3 Key findings/Evidence Standard met? Since the last inspection two staff members, the manager and a carer have been appointed. Inspection of staff files indicates that both have an enhanced CRB certificate in place. Inspection of sample care staff files, indicates that an appropriate recruitment process is followed which includes obtaining two written references and CRB checks. Staff files inspected included staff photos and appropriate proof of identity.Barnhill Road (11)Page 30 Standard 35 (35.1 - 35.8) The registered person ensures that there is a staff training and development programme which meets the Sector Skills Council workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users’. 2 Key findings/Evidence Standard met? Dates have been arranged for the manager and the care staff recently appointed to undertake the organisations induction and foundation training. Inspection of a number of staff training records indicates that staff have undertaken the organisations induction training. Training records are maintained although an inspection of a sample of records indicates that a number of staff have not undertaken updated training for a number of years. The registered person should undertake a staff team training audit identifying updated training needs where appropriate. Some of the staff have undertaken recent first aid training and fire training. Standard 36 (36.1 - 36.8) Staff receive the support and supervision they need to carry out their jobs. 3 Key findings/Evidence Standard met? The manager indicates that arrangements are in place for her to undertake appraisal in November 2004. Supervision records are maintained indicating that staff receive formal one to one with their line manager. The manager has booked in supervision dates for individual staff in November 2004. Staff indicated to the inspector that they felt well supported.Barnhill Road (11)Page 31 Conduct and Management of the HomeThe intended outcomes for the following set of standards are: • • • • • • • 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.Standard 37 (37.1 – 37.4) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. Registered manager qualified to level 4 NVQ in Management and care [by 2005]. NO2 Key findings/Evidence Standard met? The current manager of the home was appointed in September 2004. The manager is in the process of submitting a registered manager application to the CSCI. The manager indicates that she has a number of years experience in a management capacity of a care home. The manager indicates that arrangements have been made for her to undertake CIC’s four day induction course (Feb 05), three day foundation training (March 05) and appraisal skills training (Nov 04). Arrangements should be made to ensure that the manager is enrolled to undertake NVQ level 4 in management and care.Barnhill Road (11)Page 32 Standard 38 (38.1 – 38.6) The management approach of the home creates an open, positive and inclusive atmosphere. 0 Key findings/Evidence Standard met? This standard was not assessed on this occasion.Standard 39 (39.1 – 39.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users, are in place to measure success in achieving the aims, objectives and statement of purpose of the home. 3 Key findings/Evidence Standard met? Monthly Regulation 26 visits are undertaken and a report of such visits are forwarded to the CSCI. As a result of these visits the person carrying out the visit provides an action plan to the manager where necessary. CIC have recently introduced a quality monitoring tool which requires the manager to track the progress of a different service user each month against a set of service user focussed objectives covering: What have I achieved, decision making, activities, developing relationships, health, medication, diet, lifestyle, benefits, making choices, statement of purpose, service user guide, vehicle, risk assessments, advocacy, staff training, specialist equipment and staffing issues. The tool is formulated by the manager and checked by the service manager. At the time of the inspection September 2004 quality monitoring report was available for inspection, with an action plan.Standards 40 (40.1 – 40.6) The home’s written policies and procedures comply with current legislation and recognised professional standards, covering the topics set out in Appendix 2 of the National Minimum Standards for Adults (18-65). 3 Key findings/Evidence Standard met? The staff have access to CIC’s corporate policies and procedures which are kept under review. The home receives updated and amended guidance from CIC where appropriate. The previous manager adopted a range of local procedures in relation to the home and service users where appropriate in consultation with the staff group, CIC and other professionals where relevant. Staff have access to all records, policies and procedures which are kept secure and in good order for easy reference.Barnhill Road (11)Page 33 Standard 41 (41.1 – 41.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 3 Key findings/Evidence Standard met ? The organisations resident charter states that service users’s have a right of access to their records. On the day of the inspection sample records inspected appeared were secure up to date and in good order.Standard 42 (42.1 – 42.9) The registered manager ensures so far as is reasonably practicable the health, safety and welfare of service users and staff. 2 Key findings/Evidence Standard met? Staff that undertake the five day induction training receive health and safety training as part of their induction. Records relating to testing of the fire alarm and emergency lighting systems appeared to be satisfactory. Fire fighting equipment, the fire alarm and emergency lighting systems are regularly serviced with appropriate records kept. The fire risk assessment was reviewed and updated on 15/03/04. A gas certficate is in place and satisfactory. The home has a bath hoist and transfer hoist that have been recently serviced. The home has a number of wheelchairs and the manager indicated that these had been recently serviced. Since the last inspection a number of staff have undertaken fire safety training and first aid training. Plans are in place to ensure that the recently appointed care staff member undertakes first aid training.The following requires attention: • An electrical test certificate could not be located on the day of the inspection. The inspector was unable to ascertain if there was always a staff member on duty, including during the night that has undertaken first aid training and updates as required. The manager must ensure that training records are kept up to date to reflect staff training.Barnhill Road (11)Page 34 Standard 43 (43.1 – 43.7 ) The overall management of the service (within or external to the home) ensures the effectiveness, financial viability and accountability of the home. 3 Key findings/Evidence Standard met ? Records displayed in the home indicates that the home has adequate and valid insurance cover in place. It is anticipated that records in relation to the business and financial planning of the business would be made available to the inspector upon request.Barnhill Road (11)Page 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceLead Inspector Second Inspector Locality Manager DateDave O’Connor Jenni TweedleSignature Signature SignaturePublic reports It should be noted that all CSCI inspection reports are public documents.Barnhill Road (11)Page 36 PART DD.1PROVIDER’S RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Person’s comments/confirmation relating to the content and accuracy of the report for the above inspection. We would welcome comments on the content of this report relating to the Inspection conducted on 15th October 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possibleBarnhill Road (11)Page 37 Action taken by the CSCI in response to provider comments: Amendments to the report were necessary NOComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection reportNOProvider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurate Note: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 10th December 2004, which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request.You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Provider’s Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action planYESOther: enter details here Barnhill Road (11)Page 38 D.3PROVIDER’S AGREEMENT Registered Person’s statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I Mr Charles Eggleston of Community Integrated Care confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Charles Eggleston Mr Eggleston Chief Executive Officer 15.12.04Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Barnhill Road (11)Page 39 Barnhill Road (11) / 15th October 2004Commission for Social Care Inspection 33 Greycoat Street London SW1P 2QF Telephone: 020 7979 2000 Fax: 020 7979 2111 National Enquiry Line: 0845 015 0120 www.csci.org.ukS0000025220.V186738.R01© This report may only be used in its entirety. Extracts may not be used or reproduced without the express permission of the Commission for Social Care Inspection The paper used in this document is supplied from a sustainable source - 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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