Inspection on 12/07/05 for Beaconsfield Road, 39

This inspection was carried out on 12th July 2005.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Beaconsfield Road, 39 07/08/07

Beaconsfield Road, 39 27/09/06

Beaconsfield Road, 39 01/03/05

Beaconsfield Road, 39 27/07/04

Beaconsfield Road, 39 15/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 39 Beaconsfield Road 39 Beaconsfield Road Bootle Liverpool L21 1DS Lead Inspector Janet Mordaunt Unannounced 12th July 2005 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 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 Stationary 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. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 39 Beaconsfield Road Address 39 Beaconsfield Road Bootle Liverpool L21 1DS 0151 928 0087 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Expect Ltd Mr Peter John Hornby PC - Care Home Only 3 Category(ies) of LD - Learning Disability - 3 registration, with number of places 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Staffing - One staff day, one staff night, with additional support, and on call, to be reviewed when third person admitted. 2. When three persons are admitted, staff to increase to minimum of two persons. 3. Service users to include up to 3 LD. Date of last inspection 1st March 2005 Brief Description of the Service: 39 Beaconsfield Road is a mid-terraced property situated in a residential area of Seaforth.The home is registered to provide residential care for three adults. There is currently one man and one woman in residence. The home is owned by Liverpool Housing Trust and operated by Expect, formely Sefton Support Services. Car parking is available on the road at the front of the house. The home is generally well maintained both internally and externally. The main philosophy of the home is to enable service users to experience an ordinary life as possible within a domestic style environment. Independence of the service users is encouraged and appropriately supported. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspection visits are required at the home each year, this was the first. There has been no cause for any visits to the home since the last routine inspection in March 2005. The inspection was unannounced and took place over three hours. The requirements and recommendations from the last inspection report were discussed and checked with a member of staff. All of these have been met. A partial tour of the home was conducted. Care records and other required records were inspected. Records that were examined included residents care plans, daily diaries, medical notes, medication sheets, staff rotas and records of health and safety checks. There were no residents at home at the time of the visit therefore this report does not take account of their views. The care files of both residents were ‘case tracked’. Case tracking means that the inspector concentrates on the care given and experiences of one or more residents to ensure that the persons needs are recorded in their care plan and are being met. What the service does well: What has improved since the last inspection? Since the last inspection tiles in the main bathroom have been replaced. At the last inspection the hot water in the main bathroom was several degrees lower than the required temperature of 43 degrees, the temperature has since been regulated at 43 degrees following a recommendation of the last inspection. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 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. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 3 Information about the home is available in good detail enabling residents to make a choice about living there. A procedure for the admission of prospective residents shows that they are given the opportunity to try out the home so that they can make a positive choice about living there. Assessments were available for existing residents, which show that the home is meeting their assessed needs. EVIDENCE: There have been no new residents admitted to the home since the last inspection. A Statement of Purpose and resident Guide was viewed they included information for new residents about the service and facilities available at the home. Information about trial visits for prospective residents was available within the Statement of Purpose it clearly described the process that the home follows for introducing new residents. Assessment information for both residents were examined in detail, the information shows that the home is meeting their assessed needs. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 9 & 10 The service provides care plans for the residents which are regularly reviewed, one care plan did not include information about changing needs therefore there is a risk that these needs are not being met. The service has made appropriate arrangements to support one resident who has limitations to make decisions about their life so respecting the person’s rights. Risk assessments and protocols show that residents are encouraged to take responsible risks in their lives. Information about residents was stored securely to ensure that their confidences are kept. EVIDENCE: A care plan for both residents was case tracked. They both recorded a plan for all staff and the residents to follow in the areas of communication, financial information, support and assistance with behaviour, mobility, health and personal care. The member of staff told the inspector that residents talk about these areas with their key worker every month. A record of this was seen in both residents care files. Whilst case tracking the information in one residents care file it was noted that a recent assessment carried out with them identified some health care needs 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 10 that are not identified on the care plan, this could lead to care needs not being met. During previous inspections discussion have taken place about the organisations decision to transfer one resident from the home to another within the organisation. Through discussion with a member of staff and by viewing records it is apparent that the resident does not wish to leave the home. Records show that staff within the home have provided the resident who has limitations with assistance and communication support that they need to make the decision about where they live this includes the involvement of independent advocate and legal services. Risk assessments and protocols for both residents were viewed in their care plans. Risk assessments were available for both residents they have been reviewed and updated since the last inspection, ensuring that residents continue to take responsible risks. Protocols, which provide clear guidelines for managing such things as resident’s behaviour and set routines, were also viewed for both residents. All information about residents is kept securely in the office. The member of staff said that residents are able to access their information whenever they want. During discussion the member of staff showed a good understanding of the issue of confidentiality and the need to maintain it at all times. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12, 13, 15, & 17 Residents take part in a variety of activities both at home and in the local community, which are appropriate to their needs and wishes. Relationships are encouraged so that residents maintain contact with family and friends. Residents are encouraged to shop and prepare food that is healthy and enjoyable. EVIDENCE: Records and discussion with a member of staff showed that there are many opportunities for residents to take part in activities of their choice. The member of staff said that residents are supported to go shopping for their personal items as well as things for the home. They also said that residents go to many other places in the local community including the cinema, cafes and restaurants. Daily diaries and timetables viewed in both resident’s files showed that they are involved in a varied programme of activities, one resident attends a day centre during the week, another residents attends a drop in centre as and when they wish. There was plenty of fresh, tinned and frozen foods kept at the home. The member of staff said that residents are involved in choosing and buying food. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 & 20 Male carers are providing Personal support for a female resident, this has a potential for compromising the privacy and dignity of the resident. Resident’s health care is generally well recorded and monitored to ensure that their health care needs are met, however, some health care needs have not been recorded which could lead to those needs not being met. Medication was stored appropriately and records were well kept to ensure the protection of residents. EVIDENCE: The care plan of one resident shows that support and assistance is required with personal care. During discussion with a member of staff it was apparent that the care is not always provided by a person of the same gender. If this is the wish of the resident it must be recorded in their plan of care, If it is not agreed by the resident or a representative the practice must stop as there is the potential of compromising the privacy and dignity of the resident. Care plans and other records showed that the health care needs of residents are well met and recorded in good detail. Medication is administered by staff. Medication and records were examined, records were signed up to date and kept with medication in a locked cabinet in the office. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The service has a clear complaints procedure available in a format, which is easily accessible to residents. EVIDENCE: The complaints book was seen and this showed there have been no complaints made by a resident since the last inspection. A complaints procedure was available in the staff handbook. A copy of the complaints procedure was also seen with the homes Statement of Purpose and Service User Guide. A flow chart displaying pictures, photographs and large clear print describes the complaints process. The member of staff said that if a resident made a complaint it would be dealt with appropriately. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 30 The home is comfortable, well furnished and suited to the residents who live there. EVIDENCE: All of the communal areas of the home were clean, well decorated and looked homely. There is adequate private and communal space for the use of both residents. Altogether there are 3 communal rooms in the house, 2 are on the ground floor, a dining room separate to the kitchen and a lounge, which is equipped with a TV, video and DVD players. The third communal room is situated on the first floor of the home, this room is the designated smoking area for one resident and visitors. All areas of the home including resident’s bedrooms were decorated and furnished to a good standard. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 15 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32 Staff complete training that is required for them to carry out their work and which enables them to meet the needs of residents. EVIDENCE: Staff rotas showed that sufficient numbers of staff are on duty at all times. There is usually at least two staff on duty when there is more than one resident at home. One sleep in staff is on duty at night. Staff records were not available because the manager who is the only person that has a key locked them away, this is to protect staff confidentiality. A member of staff spoken with confirmed that he has completed most of the training that is required as well as training that is specific to the needs of the residents. The member of staff said that they took part in an induction programme before working at the home. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 42 Regular checks of the environment and equipment are carried out ensuring the health, safety and welfare of residents and staff. EVIDENCE: Health and safety records were examined at the home. The records were up to date and showed that the required Health and Safety procedures are carried out at the home. 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 17 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 x 3 x x Standard No 22 23 ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x 3 3 x 3 x 3 Standard No 31 32 33 34 35 36 Score x 3 x x x x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 39 Beaconsfield Road Score 2 2 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 3 x F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 18 no 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 YA6 Regulation 15(2) Requirement The manager must ensure that care plans are updated to include information about the heath care needs of one resident. The manager must ensure that personal support is provided to residents by a person of the same gender, if this is the wish of the resident it must be recorded in their plan of care. Timescale for action 31/09/05 2. YA18 12(1)(b) 12(2) 12(3) 12(4)(a)( b) 31/08/05 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 Good Practice Recommendations 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Burlington House, 2nd Floor, South Wing Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 39 Beaconsfield Road F53 F03 39 Beaconsfield Rd S5305 V243943 12.07.05 Stage 4.doc Version 1.40 Page 20 - 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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