Inspection on 21/09/05 for Bedford Road, 153

This inspection was carried out on 21st September 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Bedford Road, 153 30/01/08

Bedford Road, 153 23/11/06

Bedford Road, 153 19/01/06

Bedford Road, 153 13/01/05

Bedford Road, 153 22/04/04

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 Bedford Road, 153 153 Bedford Road Bootle Liverpool Merseyside L20 2DR Lead Inspector Mrs Janet Marshall Unannounced Inspection 21st September 2005 09:30 Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 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 Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 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. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Bedford Road, 153 Address 153 Bedford Road Bootle Liverpool Merseyside L20 2DR 0151 933 5397 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) bedford@autisminitiatives.org Autism Initiatives Mrs Elizabeth Murtagh Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 3 LD Date of last inspection 13th January 2005 Brief Description of the Service: 153 Bedford Road is a four bedroom terraced house situated in a residential area of Bootle, it is indistinguishable from other properties in the area. The property is registered as a small care home to provide accommodation for three young men who have learning disabilities. The house both externally and internally is well maintained and clean throughout. The home is operated by Autism Initiatives an organisation that provide support for people with autism. The home provides staff 24 hours a day to provide care and support for the service users who live there, the overall philosophy being to maximise ordinary living and to promote independence of the service users in all aspects of their daily life both at home and in the community. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 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 January 2005. The inspection was unannounced and took place over four hours. The requirements and recommendations from the last inspection report were discussed and checked with the manager. A partial tour of the home was conducted. A selection of 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. The residents who live at the home were all away on holiday with a group of staff therefore their views about the home were not obtained. The second inspection for this year will be arranged when all the residents are home and will include their views and life experiences at the home. What the service does well: What has improved since the last inspection? What they could do better: Care plans and other care records need to be reviewed and updated to ensure that residents needs are being met. Restrictions on residents need to be consistently recorded to show when others make decisions for them and why. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 6 An individual training plan has been provided for each member of staff, although they need to be developed further to show that training and development is linked to the aims of the service and residents needs. An annual development plan for the home needs to be provided to show a yearly plan of how the aims of the home are being met. To ensure the protection of residents staff references must be provided by those given on the original application form, if this is not the case then the reason for this and the changes must be recorded on the staff file, also verbal references must be followed up by a written reference which must also be kept on file. Some carpets need to be cleaned or replaced so that the all parts of the home are maintained to a good standard. 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. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 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 Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): These standards were not inspected on this occasion. EVIDENCE: Not Applicable Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 10 Care plans need to be reviewed and updated to reflect residents changing needs. Restrictions on residents are not consistently recorded to show when others make decisions and why. Information about residents was kept securely in the office to ensure that their confidences are kept. EVIDENCE: A care file, which included a care plan, was viewed for each resident. They provide some good information about aspects of resident’s lives including communication, financial information, support and assistance with behaviour, mobility, health and personal care. Some of the information in the care files have not been reviewed or updated since the last inspection, which took place in January 2005. There is therefore a risk that residents needs are not being identified and met. The manager said that a new way of recording and planning residents care and support needs is soon to be introduced to the home. Some residents at the home are unable to make decisions about their own lives and/or are limited in what they are able to do either because is poses a Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 10 risk to their safety or because of limitations they have. For example the use of locks and keys, opening and understanding their mail. They therefore depend on others to make decisions for them. This information must be recorded for each person. Care Plans did not include all the information about decisions that other people need to make and why. Information about residents was kept securely in the office. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 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 the following standard(s): 12, 13 & 14 The service encourages and supports residents to participate in community activities, and actively encourage residents to maintain relationships with family and friends, and consequently prevents isolation. EVIDENCE: Records showed that all residents are involved in a varied programme of activities both at home and in the local community. Records also showed that residents have regular contact with their family and friends. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 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 the following standard(s): 19 Residents personal and healthcare needs are understood, however some records need reviewing and updating to ensure that their health care needs are fully met. EVIDENCE: Details of routine and specialist health care checks were recorded in residents care files. Care files also included a good level of information about residents personal, healthcare and emotional support needs and preferences. Records showed that some of the information has not been reviewed or updated since January 2005. The manager showed a good level of understanding of residents healthcare and emotional needs. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 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 the following standard(s): 22 & 23 The service has a clear complaints procedure available in a format, which is easily accessible to residents. A regular record of money that residents have in and take out of their accounts was not available, therefore there is no guarantee that residents are fully protected from financial abuse. 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 displayed at the front entrance of the home. A flow chart displaying pictures, photographs and large clear print describes the complaints process. The manager appropriately described how she would deal with a complaint made by a resident or a member of staff. The manager said that she is working with the organisation to help residents set up bank accounts in their own name and address, which they can access when they want. The manager said that there has been some difficulties in setting up individual bank accounts for residents but is continuing with this. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 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 the following standard(s): 24 & 30 Most parts of the home were clean, tidy and maintained to a good standard providing a comfortable and safe environment for the people who live there, however some carpets and fittings need attention to ensure the safety and dignity of residents. EVIDENCE: A tour of the home was carried out. All areas are generally well maintained and decorated to a good standard. One residents bedroom is in the process of being decorated. The manager said that he was involved in choosing colour schemes. Another residents bedroom did not have a lampshade fitted to the ceiling light, one should be provided to ensure their dignity and safety. Carpets in the dining room, hall, stairs and landing were heavily stained in parts. These must be cleaned or replaced so that all parts of the home are maintained to a good standard for the residents who live there. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 Training and development plans for staff are not complete to show that training and development is linked to the aims of the service and residents needs. Staff recruitment records need to be better maintained to provide necessary safeguards and protection for people living in the home. EVIDENCE: Records showed that the manager has made some progress towards providing training and development plans for each member of staff, however they need to be developed further to show a more structured plan that includes a programme of training that meets the aims of the home and the needs of the residents. The staff files of three staff employed in the home were looked at. Two staff references did not match the details given by the applicant on their original application form. If references obtained are different from those given on the original application form the reason for this and details of the new referee must be recorded on the staff file. The reference for another member of staff was taken verbally over the telephone. Verbal references are only acceptable for the short term they must be followed up by written references, which must be also be kept on the staff file. There was evidence of Criminal Records Bureau checks having taken place for those staff. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40 & 42 The management of the home appears to be effective benefiting residents and staff. An annual development plan is not available to show how the home is meeting its aims. The required Health and Safety checks have been carried out which ensures the safety of residents and staff. The homes Policies and Procedures protect the health, safety and welfare of the residents and staff, however some of them show that they have not been reviewed for sometime so may not be relevant. EVIDENCE: The registered manager has recently returned to work following a period of absence. She has reduced her hours of work, which has been agreed by the Commission subject to a review in six months time. The deputy manager of the home has taken on the responsibility of the manager in her absence this arrangement appears to be working well to the benefit of the residents and staff. Both the manager and the deputy manager said that they are happy Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 17 with the current management situation and feel that between them the home is run well. The manager said that she has not yet developed an annual development plan for the home. This needs to be done each year to show that the aims of the home are being planned actioned and reviewed. A Health and safety manual was available at the home. The manual included certificates of safety checks and details of tests carried out on the environment, they were all well kept and up to date. All the required health and safety policies and procedures were available in the homes handbook, a number of them showed that they have not been reviewed for sometime. All policies and Procedures should show that they are reviewed regularly so that they are relevant and up to date. Other required records that were seen were well kept and up to date. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 18 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 X X X X X Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 2 X X 3 Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X X X X 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 2 2 X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Bedford Road, 153 Score X 2 X X Standard No 37 38 39 40 41 42 43 Score 3 X 1 2 X 3 X DS0000005236.V253615.R02.S.doc Version 5.0 Page 19 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)(b) Timescale for action The manager must ensure that 31/11/05 residents care plans and other care records are reviewed and updated regularly. The manager must ensure that 31/10/05 all limitations are agreed residents or their representatives, and recorded in their care plans. The manager must ensure that 31/11/05 residents have a bank account in their own name and address. The manger must arrange for 31/10/05 some carpets to be cleaned or replaced. The manager must ensure that 31/10/05 staff references match the information given on the applicants original application form. The manager must ensure that 31/11/05 an individual training plan is developed for each member of staff The manager must provide An 31/10/05 Annual Development Plan for the home. Requirement 6 2 YA7 YA23 12(2) 17(2) Schedule 4 3 4 YA24 YA34 23(2)(d) 4(b) 5(d)(i) 5 YA35 18(1)©(i) 6 YA39 24(1)(a)(b) Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 20 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 YA40 Good Practice Recommendations The manager should review the homes Policies and Procedures to make sure that they are relevant. Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 21 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House 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 Bedford Road, 153 DS0000005236.V253615.R02.S.doc Version 5.0 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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