Inspection on 09/07/07 for Barnhill Road (11)

This inspection was carried out on 9th July 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 11 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Barnhill Road (11) 23/01/07

Barnhill Road (11) 13/02/06

Barnhill Road (11) 04/11/05

Barnhill Road (11) 15/10/04

Barnhill Road (11) 19/04/04

Extracts from inspection reports are licensed from CQC, this page was updated on 28/09/2008.

CARE HOME ADULTS 18-65 Barnhill Road (11) 11 Barnhill Road Wavertree Liverpool Merseyside L15 5BE Lead Inspector Manidipa Choudhury Key Unannounced Inspection 9th July 2007 12:30 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 Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Barnhill Road (11) Address 11 Barnhill Road Wavertree Liverpool Merseyside L15 5BE 0151 733 7646 9999 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) www.c-i-c.co.uk. Community Integrated Care Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 23rd January 2007 Brief Description of the Service: 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 residents. Residents 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. On the day of the inspection the resident’s contracts were not available on the site and the manager was not able to provide the inspector with their fees. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection took place over two days, 9th July and 17th July, and lasted almost six and a half hours. A full tour of the premises took place. A range of records such as care plans, essential Lifestyle Plans, staff personnel files, policies & procedures and medication charts were examined. The Manager and a support worker were on duty. Another staff member arrived for an afternoon shift. The inspector spoke to a staff member on duty, and the three service users were closely observed during the course of this inspection. What the service does well: What has improved since the last inspection? The new Manager Lynda Sinclair has been in post since July 2006. However, she has handed in her resignation and will be leaving very soon. The home now has a full compliment of staff. Resident’s individual and joint needs are met by appropriately trained staff. Staff training and development is an area that has improved significantly. All Staff members now receive mandatory training appropriate to the work they perform. All staff members receive appropriate structured induction training and this is systematically documented. The resident’s activities schedule has also improved, and each resident has an individual weekly activities schedule. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 6 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. The summary of this inspection report can be made available in other formats on request. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 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 Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The homes Statement of Purpose and Service Users Guide are well written and comprehensive providing residents and/or their representatives and any potential residents with details of the services the home provides enabling an informed decision to be made about admission to the home. EVIDENCE: The Statement of Purpose and the Service User Guide needs to be reviewed and updated. The documents still mention the name of the last Manager. All three residents currently living at the home have been resident there for a number of years. Each resident has an Essential Lifestyle Plan (E. L. P). This document is intended to cover every aspect of a resident’s life and includes their preferences, choices, hobbies and interests and provides a detailed insight into the person being cared for and the lifestyle they wish to have. This plan is especially useful as the residents have severe communication difficulties. The individual written contract/statement of terms and conditions of the residents could not be viewed, as they are kept at the head office. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 9 The home has not taken any residents in the recent past, but the home manager assured the inspector that it is CIC’s policy to fully assess any resident before they are admitted to the home. All prospective residents are given the opportunity to visit and experience the home before they are admitted. Family members of two residents completed two service user survey forms. They both indicate that the residents and their family members are provided appropriate information regarding the care home in order to make any decisions. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Resident’s risk assessments do not reflect a true picture of the personal, environmental and functional risks presented by each resident and therefore staff members cannot enable residents to take responsible risks, ensuring they have good information on which to base decisions within the context of the home’s risk assessment and risk management strategies. EVIDENCE: The inspector case- tracked two residents. All the residents in the home have a comprehensive and detailed individual care plan. In the case of one resident the care plans are being reviewed every 6 to 9 months. However, in case of the second resident, there was no evidence of the document being reviewed regularly. Parts of the care plan have now become irrelevant, as the resident’s care needs have changed. The care plan has been drawn up in 2004 and not been appropriately updated. At present a review entails a date and an initial to Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 11 suggest that the review has been undertaken. This is insufficient. Following a review the Key Worker or whoever is undertaking the review should evidence that they have looked at all aspects of the care plan, document any changes or significant developments during the period and how it affects the resident, include comments on the resident’s general well being during the period and all changes should be recorded and actioned. Each resident has an Essential Lifestyle Plan ( E.L.P) which records resident’s individual choices and preferences, interests and hobbies, social history, daily routines and documents that which is important to the individual resident. The Essential Lifestyle Plans show that the resident and /or their relatives are involved in the care planning process. The Essential Lifestyle Plans have been drawn up in 2004. In the case of one resident, the Essential Lifestyle Plan has been reviewed in 2007, but the Essential Lifestyle Plan of another resident has not been reviewed since 2004. Personal and environmental risk assessments are completed for each resident. The functional risk assessments for the service users need to be reviewed and updated. Some of the risks in case of certain residents are no longer relevant. In such cases they have just been cut across with a pen or written over by applying white ink. The registered person and the manager needs to ensure that a separate risk assessment is drawn up with regard to the use of overhead tracking which was introduced at Barnhill Road in October 2006. It has been included in the risk assessment for bathing and does not seem relevant. Most parts of the resident’s risk assessments have not been reviewed in the last 6 to 9 months. Care plans show that service users and /or their relatives are involved in the care planning and review process. Full involvement of NHS and other healthcare professional agencies was clearly evident on all service user care plans examined. Care practices are lead by the individual needs of residents and a focus on resident’s rights and preferences. All three residents at the care home require the intervention of staff for all their personal support and health care needs. Staff spoken to during the inspection were fully aware of the personal support needs of the residents and how important it was that those needs should be met in a way that is sensitive to the resident’s preferences. On the day of the inspection the inspector observed a care worker and the manager feeding the residents with sensitivity and with appropriate consideration given to their dignity. In a resident’s survey conducted by the home, the relative of a resident has commented that “I am very happy with the CIC service”. The relative of Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 12 another resident has said that “CIC gives her family member “a good quality of life”. Family members of two residents completed two service user survey forms. They both indicate that the care service is capable of meeting the individual and varied needs of the residents. They also indicate that the care home meets the needs of their relative appropriately, and provide the appropriate level of support and care to their respective relatives. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 13 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are actively encouraged and supported by the staff team to participate as much as possible in age appropriate activities which enhances their quality of life. EVIDENCE: All three residents have an Essential Lifestyle Plan, which details their individual interests hobbies and aspirations. They all require the support of staff to participate in any social or leisure activities. Since the last inspection an activity plan has been drawn up for each individual resident, that presents a picture of what each resident does through the week. The activities include visits to the sensory room, trips out in the car, shopping Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 14 trips, visits to the park, going for walks, visits to the pub, video-club night and sing alongs. The Aroma therapist visits two residents on a fortnightly basis. The manager explained that the third resident does not enjoy these sessions, and therefore does not participate. The manager explained that they if they undertake any activities in addition to those mentioned in the individual resident plans, they try to note them down in the daily diary sheets. Each resident has a designated key worker. Each key worker is supposed to write a bi-monthly report that reveals any special activities that may have been planned and executed. One particular resident had been on a trip to Brighton and had also gone bowling. However, these records are not always kept meticulously. It is therefore recommended that the manager maintains an activities diary to keep a record of all activities organised on a daily basis. All three residents require staff support and assistance at mealtimes. None of the service users are on a pureed diet. The food needs to be cut into small pieces. Due to the complex nature of their disabilities and the lack of communication, none of the residents can participate in drawing up a menu plan. The staff members explained that some of the staff who have been at the home for a long time can pick up specific signs which tells them which meals a service user enjoys. The home has a menu plan, but they don’t always follow them. The manager explained that following from the recommendation made at the last inspection, they note down what each resident has ate in the daily diary sheets. Family members of two residents completed two service user survey forms. They both indicate that the care home provides all relevant support to enable them to keep in touch with their relative. They are always provided up to date information with regard to important issues affecting their relative. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Medications are managed safely in accordance with the National Minimum Standards, thereby ensuring that the residents are protected by the home’s policies and procedures for dealing with medications. EVIDENCE: Each resident has a Health Action Plan. All visits by health care professionals are documented. The Chiropodist visits the home every three months. None of the current residents in the home self medicate. The key-workers and the manager of the home administer medications to the residents. All staff members have had appropriate training on administration of medication and the administration of rectal diazepam. The Medication administration Record Sheets were viewed and the standard of record keeping found to be satisfactory. The medication file contains a list of the resident’s medications, information about the medication and possible side effects. Following the last Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 16 inspection a copy of the medication policy has been kept in the medication file along with the MAR sheets. Bed rails and bumpers are used for some residents. An appropriate risk assessment must be done on this issue and kept in each resident’s care file. The Manager has put up a notice and illustration regarding the correct procedure for the use of bed rails and bumpers on each of the resident’s rooms where applicable. The manager is a qualified moving and handling facilitator, and she has trained all staff members on this issue. It is recommended that the manager contact the District Nurse and request them to do a formal risk assessment regarding the use of bed rails and bumper, and also to give staff some basic training on this subject. Appropriate documentation should be kept of all assessments and training imparted by the district Nurse. From observations during the inspection, it appears that staff members provide sensitive and flexible personal support and care to maximise the resident’s privacy, dignity, independence and control over their lives. Personal support is provided in private, and intimate care by a person of the same gender is provided if that is the resident’s wish. In a resident’s survey conducted by the home the relative of a resident has commented that “ I am satisfied with the care” my relative “receives from staff”. Family members of two residents completed two service user survey forms. They both indicate that the care service supports residents to live the life they choose. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Barnhill has a comprehensive complaints system and appropriate checks are made on all staff to ensure the protection of residents. EVIDENCE: A clear complaints policy and procedure is available for both residents and their representatives. The complaints policy is displayed on the notice board in the entrance hall of Barnhill Road. The complaints policy still has the NCSC name and address. It is recommended that the registered person changes this to CSCI with appropriate telephone number and address. The home has not had any complaints since the last inspection. CSCI too have not received any formal complaints with regard to Barnhill Road. They have a record of complaint form to take down information on any complaints received. The three residents are unable to communicate verbally but staff said that they were able to use non-verbal communication if they were unhappy. Since the last inspection most of the staff members have had appropriate POVA training. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 18 Family members of two residents completed two service user survey forms. They both indicate that they are aware of how to make a complaint pertaining to the care of the resident if the need arises. They have also indicated that the care home has always responded appropriately if the resident or their relative have raised any concerns pertaining to the care of the residents. One relative has commented that he has “no complaints” and that he is “very happy with the service provided”. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The standard of the environment within Barnhill Road is good, providing residents with an attractive and homely place to live. EVIDENCE: The home is situated in the Wavertree area of Liverpool and is close to shops and other amenities. The home is a three bedroom bungalow leased from Maritime Housing Association. The home is warm, comfortable and homely and on the day of the inspection odour free. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 20 Each resident’s bedroom is individualised to reflect their personal taste and preferences, all three service users bedrooms have overhead tracking equipment with individual slings to assist safe moving and handling. The Manager explained that a walk-in-shower is going to be installed very soon, as the existing bath is not suitable for some of the residents. The funding has been approved and the work will be done in 2007. The main lounge carpet is now faded and in a poor state. The manager explained that as some of the resident’s have incontinence problems, they would prefer to have laminated flooring. The registered person is required to replace the lounge carpet. One resident’s bedroom flooring is in an unsatisfactory state and needs to be replaced. The trees at the side of the house overhang the rear garden this could prove to be a hazard if they were to break and snap off. They are a potential health and safety risk and need to be pruned to reduce this risk. This is an ongoing issue, and the Manager explained that they are still trying to negotiate with the owners of that plot of land to address this issue. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 21 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has an effective staff team, with sufficient numbers and complementary skills to support resident’s assessed needs at all times. EVIDENCE: A random selection of staff personnel files was viewed, and were found to be satisfactory. Personal records of staff members are kept separately from their training records. Staff records have been kept in a systematic and organised manner. All the staff members have appropriate POVA and CRB checks. In the case of one staff member, only one reference could be found. The registered person must ensure that two written references are obtained before making an appointment and any gaps in the employment record explored. Each staff member has a contract, and a copy of this is kept in his or her personnel file. It is recommended that all staff members are issued with an appropriate job description and a copy of this should be kept in his or her personnel file. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 22 Staff members have had relevant training on mandatory topics in 2007. This includes topics like food hygiene, medication, POVA, moving and handling, health and safety and first-aid. CIC has a comprehensive induction process. It is done through E-learning and then they go to the training centre for practical days. Evidence was seen on the laptops. It includes core skills like Confidentiality, Manual handling, Health and safety at work, first-aid and working relationships. Staff house meetings are held every month. The minutes of the last staff meeting was seen. The manager explained that they do telephone link ups with staff members who cannot attend the meetings, giving them an equal opportunity to participate and comment on house issues. Of the 8 staff members, 1 staff member has completed NVQ level 3 and 4 staff members are doing their NVQ level 2. They are due to complete next week. The manager has started establishing arrangements for regular recorded supervision meetings with staff members. Evidence of this was viewed during the inspection. In a resident’s survey conducted by the home the relative of a resident comments that “All the staff are caring and very helpful”. Family members of two residents completed two service user survey forms. They both indicate that the relatives are confident that the staff team at the care home have the right skills and experience to look after the residents appropriately. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 23 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Records required by regulation the protection for the protection of service users and for the effective and efficient running of the business are not kept accurately and up to date thus compromising the health, safety and welfare of residents. EVIDENCE: The current Manager has been in post for nearly a year, but has not been formally registered with CSCI. The manager informed that she has recently handed in her resignation, and will be leaving soon. She has been asked to continue for a while longer. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 24 The accident book was viewed, and there have been no recorded accidents since the last inspection. Fire drills are conducted twice or thrice a month, but the manager does not record the names of the staff members who have attended the drill. It is recommended that the manager record the names of the staff members who attend each fire drill, to ensure that all staff members are regularly attending fire drills. Fire equipment is serviced on a quarterly basis. At present fire alarms are being tested on a fortnightly basis, but they should be tested weekly and appropriately recorded. Appropriate fire risk assessment has been done. The manager informed that the emergency lighting system has been serviced on 14/06/07, but the appropriate certificate could not be found. Similarly, certificates for 2005 and 2006 could not be found. The manager explained that fire training is conducted whenever a fire drill is held, but appropriate records are not kept. It is recommended that appropriate fire training records are kept in the staff training files to evidence that all staff members receive fire training. The Manager, who is an approved fire trainer, does fire training. She has been trained by the Merseyside Fire Brigade. The home has a relevant gas safety certificate, but the electrical safety certificate is not kept at the home. It was later faxed to the CSCI office. It is apparently kept at the head office. It is recommended that a copy of this certificate be always kept on the premises. Potable appliance testing has been done on 06/02/07. A hoist is used for a particular resident, but there was no evidence that this equipment is serviced on a regular basis. All the residents use wheelchairs. There is no documentary evidence that these are serviced on a regular basis. The manager said that they call technicians out as and when required to service the wheelchairs, but no records are kept. Appropriate COSHH assessments have been done in 2006 and reviewed in 2007. Water temperature records are not being kept in a systematic and orderly manner. With regard to Quality Assurance, a Health and Safety checklist has been introduced recently. The list goes through all the health and safety checks (eg COSHH, first aid, wheelchairs, water temperature etc ) to record whether it is satisfactory. A monthly core standards review/audit is also undertaken. It looks at areas like staff recruitment, staff supervision, training, etc. A copy of this report is sent to CSCI. The manager has started doing service user surveys in 2007. The responses were viewed during the inspection. Family members of two residents completed two service user survey forms. One relative has commented that keeps my relative “clean, safe and happy” and provides a “high standard of care”. Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 25 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 3 3 3 4 3 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 2 26 3 27 2 28 3 29 3 30 3 STAFFING Standard No Score 31 3 32 3 33 3 34 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 3 2 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 3 2 2 2 Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 26 Yes 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. 1. Standard YA5 Regulation 5 Requirement The registered person must ensure that each service user has an individual written contract or statement of terms and conditions with the home. A copy of the contract should be kept in the individual service user file. The registered person shall ensure that all staff members, including night staff attend fire drills at regular intervals and that this is systematically documented. This requirement remains outstanding from the last inspection. The registered person shall ensure that the service user care plans are systematically reviewed at regular intervals and updated to reflect the changing needs of the service user. This requirement remains outstanding from the last inspection. Timescale for action 30/10/07 2. YA42 23 15/09/07 3. YA6 15 15/09/07 Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 27 4. YA24 23 The registered person must ensure that the furnishings and fittings at Barnhill Road are of a good quality. The main lounge carpet is old, worn out, faded and dirty in places. This needs to be replaced. The registered person should provide each resident with a bedroom that has furniture and fittings sufficient and suitable to meet individual needs and lifestyles. One resident’s bedroom flooring is in a unsatisfactory state and needs to be replaced. The registered person must ensure that fire alarms are tested on a weekly basis, and that the results are systematically recorded. 15/11/07 5. YA26 23 15/11/07 6. YA42 23 01/09/07 7. YA42 23 The registered person must 30/09/07 arrange for persons working at the care home to receive suitable training in fire prevention Appropriate fire training records are to be kept in the staff training files to evidence that all staff members receive fire training at regular intervals. The registered person must arrange for the maintenance of all fire equipment. The emergency lighting system should be serviced regularly and appropriate records kept in a systematic manner. The registered person needs to ensure that when bed rails are in use, an appropriate risk assessment is undertaken by a competent person. This is kept DS0000025220.V338053.R01.S.doc 8. YA42 23 30/10/07 9. YA42 13 30/10/07 Barnhill Road (11) Version 5.2 Page 28 under constant monitoring and review. All staff members handling it have the necessary training. This requirement remains outstanding from the last inspection. The registered person must ensure that equipment provided at the care home for use by residents are maintained in good working order, and appropriate records are kept to evidence this. The registered person needs to ensure that two written references are obtained before making an appointment and any gaps in the employment record explored. This requirement remains outstanding from the last inspection. 10. YA42 23 01/10/07 11. YA34 17 15/10/07 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 YA9 Good Practice Recommendations It is recommended that the registered person and the manager ensure that a separate risk assessment is drawn up with regard to the use of overhead tracking that was introduced at Barnhill Road in October 2006. The registered person needs to ensure that the Statement Of Purpose and the Service User Guide is reviewed to include the most up-to-date information regarding the home. 2. YA1 Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 29 3. YA9 The registered person should make adequate arrangements to ensure that the service user risk assessments are reviewed and updated at regular intervals, and this is clearly documented. It is recommended that when a resident’s care plan or risk assessment has changed significantly or become irrelevant, it should be re-written completely with the consultation of the resident, their family members, other significant individuals and other professionals involved with the resident’s holistic care. It is recommended that the manager maintains an activities diary to keep a record of all activities organised for the residents on a daily basis. The complaints policy displayed at the home, still has the NCSC name and address. It is recommended that the registered person change this to CSCI with appropriate telephone number and address. It is recommended that all staff members are issued with an appropriate job description and a copy of this should be kept in his or her personnel file. The trees at the side of the rear garden are overhanging and require pruning to limit the threat to the service users health safety and welfare. It is recommended that the registered person negotiate with the owner of the property, where the tree is located, to resolve the problem. It is recommended that appropriate fire training records are kept in the staff training files to evidence that all staff members receive fire training. It is recommended that efforts be made to ensure that individual records and home records are maintained in an organised and systematic manner. It is recommended that the registered person makes suitable arrangements for the maintenance of electrical systems, and appropriate records are systematically kept. It is recommended that water temperatures are monitored on a regular basis and appropriate records are systematically kept. 4. YA6 5. YA14 6. YA22 7. YA31 8. YA24 9. 10. YA35 YA41 11 12 YA42 YA42 Barnhill Road (11) DS0000025220.V338053.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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