Inspection on 07/08/07 for Beaconsfield Road, 39

This inspection was carried out on 7th August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Beaconsfield Road, 39 27/09/06

Beaconsfield Road, 39 12/07/05

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 Beaconsfield Road, 39 39 Beaconsfield Road Bootle Liverpool Merseyside L21 1DS Lead Inspector Mrs Janet Marshall Unannounced Inspection 7th August 2007 09:30 Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Beaconsfield Road, 39 DS0000005305.V345782.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. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Beaconsfield Road, 39 Address 39 Beaconsfield Road Bootle Liverpool Merseyside L21 1DS 0151 928 0087 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) Expect Limited Mr Peter John Hornby Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Staffing - One staff day, one staff night, with additional support, and on call, to be reviewed when third person admitted. When three persons are admitted, staff to increase to minimum of two persons. Service users to include up to 3 LD Date of last inspection 27th September 2006 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 are currently two men in residence. The home is owned by Liverpool Housing Trust and operated by Expect, formerly 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. The fees for the home start at £318.00 per week. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection. The Commission considers 22 standards for Care Homes for Adults as Key Standards, which have to be inspected during a Key Inspection. The report has been put together using information gathered from a number of sources including information that the commission have received about the service since the last inspection and details provided in the Annual Quality Assurance Assessment (AQAA). The AQAA, which is in two parts, a selfassessment and dataset, has replaced the pre-inspection questionnaire. The document, which is sent out to, the service has to be completed and returned to the commission before an inspection takes place. The AQAA for this service was completed in good detail and returned within the timescale given. A number of surveys were sent out to people before the inspection but none of them were returned. The inspection also involved an unannounced visit to the home (site visit). Records that were examined, people’s comments and observations made during the visit have also been used as evidence for the report. All the residents that live at the home have limited verbal communication skills so were unable to express their views and opinions about the service. However, a number of residents were case tracked. This process involved talking to staff and looking at residents records such as assessments, care plans and daily notes to get an idea about peoples experiences and to find out if they are receiving the care and support that they need and have agreed to. The manager Susan Gallon was not on duty on the day of the site visit. A senior support worker and other staff that were on duty assisted with the inspection, they were all very helpful. What the service does well: Available at the home are a number of detailed policies and procedures, which clearly described the processes for assessing and admitting new residents to the home. These ensure that people make the right choice about living there. Records showed that before moving in a new resident was given information about the home and other opportunities to help them decide if it is the right place for them to live. Completed care plans were in place for two residents and clearly set out how staff need to support residents enabling them to live independent, healthy, safe and enjoyable lifestyles. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 6 Staff were seen and heard treating residents in a respectful way. Their attitude and approach towards residents and each other ensured residents privacy and dignity at all times throughout the inspection. The home has in place easy read procedures for responding to concerns and complaints and for ensuring that residents are safe from abuse, harm or neglect. The commission have not received any complaints about the home since the last inspection. Everybody spoken with during the inspection said that they understand the homes complaints procedure and now how to make a complaint if they needed to. People knew who to talk to if they were unhappy about something and were confident that their complaints would be listened to and dealt with in the correct way. The service employs people of various age and gender and from different ethnic groups. Available at the home was an equal opportunities policy and procedure, which promotes equality for all. The service have made plans for staff to attend equality and diversity training based around the Race Equality Kit, promoted by Sefton council for voluntary services. More than half of the staff team have achieved or are working towards a National Vocational Qualification in Care level 2 and above. Staff are involved in an ongoing programme of training, which is relevant to the work that they carry out. Staff showed a real committed to both mandatory and specialist training so that they have up to date knowledge of current good practice and law. A comprehensive detailed set of polices and procedures were available at the home. The polices provided clear information which help staff make the right decisions and take actions which are law and in the best interests of the residents. The procedures clearly described the steps that people need to take to fulfil the policy. All policies and procedures have been reviewed and updated since the last inspection to ensure that they are relevant and up to date. People spoken with were confident that the home is managed well comments made during the inspection to support this included: “The “The “The “The manager manager manager manager is very supportive” is very positive and encouraging” cares a lot about the residents and staff” is very good at her job” Records that were examined at the home were well organised, up to date and accurate ensuring that residents health, safety and welfare are safeguarded. What has improved since the last inspection? Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 7 Residents with limited verbal communication skills are given better opportunities to communicate by other means so that they have more control of their own lives. The health and safety of one resident is better protected now that more information and a risk assessment have been provided detailing a specialist health condition. All staff have must undertaken protection of vulnerable adults training so that they know how to respond appropriately to suspicion or evidence of abuse or neglect. A number of improvements have been made to the environment making it safer and more comfortable for the people that live, visit and work there. 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. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 8 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 Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 9 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): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures carried out at the home ensure that prospective residents choose a home, which is right for them. EVIDENCE: One new resident has been admitted to the home since the last inspection. The resident’s personal file contained a copy of an initial needs assessment, which was carried out by qualified people prior to the person moving into the home. The Assessment, which was viewed covered in detail areas of the persons needs such as personal support, education and training, family/social contact, management of risk, physical and mental health care, communication and financial support. The assessment along with additional information provided by other people such as previous carers and college tutors provided enough information upon which to develop a care plan. Available at the home were a number of policies and procedures for assessing and introducing new residents to the home. A member of staff who was on duty at the time of the visit clearly understood them. Available in each of the residents personal files was a contract detailing the terms and conditions of their placement. Contracts were available in an easy read format. Pictures and symbols supported large clear print so that people with communication difficulties can easily understand it. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 10 The contract for the new resident had not been signed or dated therefore there was no guarantee that the terms and conditions of the placement have been agreed. The resident does not have the ability to do this. It was therefore recommended that this be done with the involvement of an independent advocate or somebody else who is not directly linked to the home such as a social worker. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 11 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): 6, 7 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff have a good amount of information to enable them to support residents to live independent and safe lifestyles. EVIDENCE: Residents had their own personal file, which was kept securely at the home. Each file contained a care plan. All care plans was looked at as part of the case tracking process. The plans were made up of a number of sections covering all aspects of each person’s personal and social support such personal care, independent living skills, healthcare, accessing the community, relationships, finances and a personal development plan. Information about how best to support the person was part of the persons care plan. Each persons care plan is reviewed every month to ensure that the information recorded is relevant and up to date. Records, which were seen, evidenced this. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 12 Two residents care plans were completed in good detail. The other one was only part complete. The reasons for this were discussed with a member of staff. Viewed at he home was a good amount of information including assessments to enable the staff to complete the care plan. The care plan should be complete so that staff have the information they need to fully meet the needs of the resident. Completed care plans were signed and dated by relevant people to show their involvement in them. All the residents that live at the home have limited verbal communication skills however they are able to communicate clearly using other methods such as body language, sounds and gestures. Care plans provided details about each persons preferred methods of communication. Staff were seen communicating with each of the residents by use of these methods. On the day of the visit residents made choices and decisions about such things as what to eat and what activities they took part in. It was recommended as part of the last inspection for one resident to be offered more opportunities to make everyday choices. This was because the last inspection evidenced that staff were making a lot of choices on his behalf. Staff felt they knew the persons well enough to know what things he liked best, for example, what to eat. Discussion with staff and examination of records during this visit showed that the resident is now encouraged to make more choices about such things as the food he eats and the clothes he wears. Staff were observed throughout the visit offering the resident choices. A member of staff said: “ Helping residents to communicate is important because it helps them to be independent. Residents here are supported to make choices and decisions about food, activities and choosing what clothes they wear each day”. None of the residents are able to manage their own finances. Financial support is given by staff. The support that residents need was recorded in their individual plan of care. Residents money and financial records that were examined were well kept and in good order. Residents had a bank account in their own name and address. Statements and records of all transactions made were available at the home. For safety reasons there are certain restrictions placed on residents for example access without support to certain parts of the home and the community. All of the residents rely on staff to make a lot of decisions and choices on their behalf. This is because making certain choices and decisions alone is likely to pose a risk to their safety. Restrictions placed upon people and choices, which need to be made by others and the reasons why, were recorded in the individual’s plan of care. Risk assessments were part of each persons care plan. They have been carried out for tasks and activities which residents are involved in that are likely to pose a risk to them. Risk assessments that were seen identified Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 13 potential risks and hazards and detailed the action that staff need to take so that residents are able to take risks safely as part of an independent lifestyle. Risk assessments that were viewed showed that they have recently been reviewed and updated. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 14 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): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to live enjoyable, fulfilling and healthy lifestyles. EVIDENCE: Each resident had an activity timetable as part of their care plan and they were all looked at as part of the case tracking process. In term time one resident attends college during the week other residents are supported to take part in a variety of activities both at home and in the community. Care plans included an section which provide details about residents hobbies and interests and how people prefer to spend their time during the day, evening and at the weekends. Where appropriate and with the necessary support residents are encouraged to help out with general routines around the home such as vacuuming, polishing and preparing meals. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 15 The AQAA detailed various activities that residents are involved in on a regular basis they include, trips out to the seaside, country, and garden centres, shopping and meals out. A selection of daily notes, which were viewed, confirmed resident’s involvement in these activities. Following assessments and were appropriate residents are provided with lockable facilities and locks on their bedroom doors. If they have not got locks information detailing this and the reason why was available in their care plan. The visitor’s book showed that residents receive Visitors at home. There were a number of entries recorded in the homes visitors book to show this. A residents relative visited the home during the inspection visit. They said that they have always been made to feel welcome when visiting the home and can visit at any time. Residents are encouraged to maintain contact with family and friends and personal relationships are respected and appropriately supported. Staff showed a good understanding of personal relationships and were sensitive to the needs of the residents in relation to supporting certain relationships. Care plans detailed relationships, which are important and need to be supported. Menus which where viewed at the home showed a variety of healthy meals. Staff explained that the menus could be changed to suit the needs and preferences of the residents. Staff showed a good awareness of the importance of nutritious and balanced diets. Staff confirmed that they have undertaken training in food safety and nutrition. Two of the residents sit at the dining table in the dining room at meal times, another resident prefers to sit alone at the table in the activity room. A member of staff said there are times when residents choose to eat their meals in the lounge, outside in the fine weather or their own rooms. On the day of the visit a resident sat outside and ate his lunch with their relative. A good stock of fresh, frozen and tinned food was seen at the home. There were also sufficient crockery cutlery pots and pans, which were of good quality. There was a fridge, freezer washing machine and microwave which were all of a domestic style and in good condition. A member of staff confirmed that residents are always involved in shopping for food. One resident indicated that he enjoys pushing the shopping trolley around the supermarket. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 16 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): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive a good level of personal and healthcare, which ensure they are respected and stay well. EVIDENCE: Care plans provided detailed information about the type and level of personal and healthcare support that each person requires. The persons preferred routines with regards to personal care were also available in very good detail. A member of staff provided personal support for one resident during the visit. The member of staff supported the resident in private and was heard treating them with respect. During Discussion staff gave a number of examples of how they ensure that residents privacy and dignity is maintained and respected. “I always chat with the person when helping them with personal care” “I always close the door” “I make sure that the floor is dry and the bath is clean” “I always knock on doors before entering a room which may be occupied by a resident” Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 17 “When assisting a resident with personal care it is important to make sure that they feel relaxed. I talk to them to help with this”. Care plans included a section, which covered in detail the person’s healthcare, needs and the support that they need to stay well. Records within this section showed that residents are offered minimum annual checks and that there health is regularly reviewed and monitored and dealt with appropriately. As well as visits to primary healthcare services such as dentist, opticians and doctors residents are also supported to attend specialist services. Records detailing the visits were available in good detail as was information about specialist health care needs and requirements. Where appropriate visits to the home by healthcare professionals are arranged. A requirement was given as part of the last inspection for one residents care plan to include more information so that staff can identify and deal with potential complications regarding a specialist healthcare need. The information has been made available it was viewed in the healthcare section of the persons plan of care. During this inspection visit all medication and medication administration records were examined. Medication and records were stored in a locked cabinet in the office. Discussion with staff and examination of records showed that staff have completed medication awareness training. A policy for the safe handling and administration of medication was availble at the home. A member of staff showed a good awareness of the homes medication polices and procedures. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 18 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): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff receive the necessary training and have access to a detailed and up to date set of policies and procedures, which aim to ensure that people are, protected from abuse, harm or neglect. EVIDENCE: There has been no complaints received by the Commission about the home since the last inspection. Information provided in the AQAA and examination of the homes complaints book evidenced that there have been no complaints made at the home in the last 12 months. The home had available a complaints procedure in written and pictorial format. Both included clear information about the stages and timescales involved in the process so that people are clear about how to make a complaint if they wish to. Discussion with staff showed that they are aware of the home complaints procedures and are confident about telling somebody if they were uphappy. The following comments made by staff supported this: “Yes I most definitly would make a complaint if I was unhappy about something” “I have read the complaints procedure and understand it” “The complaints procedure is in the staff handbook. I would make a complaint” a relative visiting the home at the time of the inspection said, “I have no complaint, “I would make a complaint if I needed to” Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 19 A copy of the local authorities protection of vulnerable adults procedure was avaialbe at the home. Staff spoken with were able to describe confidently what action they would take if they suspected or evidenced that a resident was being abused. They confirmed that they had completed up to date protection of vulnerable adults training. Detailed in the AQAA were a number of other polices, procedures and codes of practice which are available the home and aim to protect residents from harm abuse or neglect, they include gifts to staff, Recruitment of staff and Whistle blowing. Staff spoken with during the visit showed a good awareness of these documents. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 20 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): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a homely environment that is comfortable and free from hazards. EVIDENCE: A tour of the home was carried out as part of the site visit. The home is a terraced property located in a popular residential area of Seaforth, Liverpool, it is close to public transport links such as trains and buses. The house is in keeping with others in the neighbourhood and does not stand out as a care home. Parking is available directly in front of the house on the street. It has four bedrooms and a number of shared rooms over two floors. All bedrooms are upstairs. Residents the fourth one doubles up as the office and staff bedroom occupy three bedrooms. The main bathroom, which is also upstairs, is close to all bedrooms and easily accessible to residents. There is a toilet/shower room downstairs off the hallway. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 21 Downstairs are two lounges, a dining room and a kitchen. One of the lounges, which were equipped with a music centre and games, is used as an activity room. The main lounge, which is at the front of the house, was comfortably furnished and equipped with a TV, video and DVD player. Occasional tables, cushions, lamps, pictures and ornaments, which were displayed around the home gave it a warm and homely feel. The premises are fitted with a number of handrails to help residents get about the house more independently. Residents and staff were welcoming and there was a warm and friendly atmosphere at the home. A number of improvements have been made to the environment since the last inspection. The AQAA provided details of them. The site visit evidenced that since the last inspection some furniture has been replaced and some parts of the home have been redecorated making it more comfortable for residents. New furniture included replacement sofas in the main lounge and dining set in the activity room. The entrance porch, kitchen and shower rooms have all been redecorated. New Floor covering has been fitted to the kitchen, bathroom and shower room. Detailed in the AQAA were a number of processes, which are carried out at the home to ensure the environment is well maintained, comfortable and safe for the people that live there. Internal audits, questionnaires and family feedback were given as examples of how this is done. The AQAA detailed plans for a number of improvements in the next year including the redecoration of the hallway including the replacement of the stair rail and radiator cover in that area. All parts of the home were clean and tidy on the day of the visit and there were no hazards identified. Discussion with staff and residents showed that residents are encouraged and supported to help keep their home clean and tidy. Cleaning routines showing the people responsible for carrying them out were in place. Detailed in the AQAA were a number of policies and procedures, which aim to ensure a clean and hygienic environment for all they included, Infection control, health and safety, and disposal of waste. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 22 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): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Details provided in the AQAA showed that there are 6 full time staff and 1 part time staff that work at the home and provide personal care for all the residents. The AQQA shows that staff are from different ethnic groups and are of various age and gender. There was an equal opportunities policy and procedure available at the home. The policy was discussed with a number of staff that clearly understood it. The service employs people of various age and gender and from different ethnic groups. The AQAA stated that the service have made plans for staff to attend equality and diversity training based around the Race Equality Kit, promoted by Sefton council for voluntary services. Discussion with staff and details provided in the AQAA show that well over half of the staff group have achieved or are working towards an NVQ Level 2 or above in care. Staff records could not be examined because for the purpose of confidentiality the manager who wasn’t on duty at the time of the site visit locked them away. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 23 Details provided in the AQAA confirm that all people who have worked in the home in the past 12 months had satisfactory pre-employment checks. A number of staff that have recently started work in the home also confirmed this. One new member of staff explained the process that they went through before they were allowed to start work in the home this included, completion of an application form including the details of at least 2 references, stage one and two interviews and completion of a CRB check. The member of staff also confirmed that they were given a copy of their job description. Another member of staff said that they completed an induction programme during the first part of their employment. They described the programme, which included emergency procedures, the structure of the organisation and foundation training in areas such as health and safety, protection of vulnerable adults and the workers role and responsibilities. There was 3 staff on duty at the time of the visit Staffing levels have increased since the last inspection to provide one to one support for the new resident. An extra support worker has been appointed on each shift so there are now 3 staff on duty throughout the day when all the residents are at home and two sleep – in staff on duty each night. Staffing rotas, which were examined, evidenced this. Staff spoken with agreed that the current staffing levels are sufficient in meeting the needs of the residents. Staff were observed interacting well with residents. They spoke to them in a polite and sensitive way. Case tracking and discussion with staff showed they have good knowledge and understanding of each of the residents. Staff were able to clearly describe each persons daily routines and preferred lifestyles. During discussion a member of staff confirmed that they have completed or have training planned in all areas of mandatory training including none violent intervention, fire awareness, food hygiene, first aid, medication awareness, moving and handling, Protection of vulnerable adults and health and safety. A member of staff said, “we are provided with a lot of training throughout the year, the training is very good”. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 24 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): 37, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The rights and best interests of the residents are safeguarded by the management style of the home. EVIDENCE: Mrs Susan Gallon is the appointed manager of the home. The AQQA confirmed that Mrs Gallon is in the process of completing an application for her approval as the registered manager of the home. It also confirmed that she is progressing well with NVQ Level 4 in care and the Registered Managers Award. She also undertakes regular training to update her knowledge and skills whilst managing the home. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 25 Mrs Gallon was not on duty at the time of the site visit, however during previous inspections she has shown a good understanding of her role and responsibilities as the manager of the home. The AQAA stated that the manager has a job description and understands her role in the day-to-day management of the home and the welfare of the residents. All staff spoken with agreed that the manager has the ability to do her job very well. They made the following comments to support this: “The manager is very supportive” “The manager is very positive and encouraging” “The manager cares a lot about the residents and staff” “The manager is very good at her job” The AQAA detailed a number of processes that are in place at the home to check the quality of the service. Some of them were discussed and checked with staff during the site visit. Daily handover checklists, regular staff meetings monthly and 6 monthly internal audits, questionnaires were some of the processes detailed. The health safety and welfare of residents are well protected this was supported by a comprehensive and well presented set of policies and procedures. The AQAA showed that the home have in place all the policies and procedures which are required by regulation for this service. It also showed that they have all been reviewed and updated since the last inspection. Discussion with staff and examination of a selection of the documents showed that since the last inspection a number of them have been provided in easy read format so that people with communication difficulties have a better understanding of them. The AQQA confirmed that in the near future the service intend to provide more information for residents in this way. Information provided in the AQAA and examination of a selection of health and safety records showed that the required health and safety checks have been carried out on the environment at the required intervals, for example fire system checks, gas and electricity checks and environmental risk assessments. A member of staff confirmed that the fire alarm system and water temperatures are tested weekly. Staff spoken with confirmed that they have completed training in areas of health and safety such as fire safety and first aid. Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 26 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 X 2 3 3 X 4 X 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 3 X 3 X X 3 X Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 27 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA5 Good Practice Recommendations Residents should sign and date their contracts to show that they agree to the terms and conditions of the placement. Family, friends and/or an advocate should support those unable to do this. Care plans should be completed so that staff have the information about the needs of the resident and how best to support them. 2. YA6 Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 28 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. Extracts may not be used or reproduced without the express permission of CSCI Beaconsfield Road, 39 DS0000005305.V345782.R01.S.doc Version 5.2 Page 29 - 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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