Inspection on 23/01/06 for Belvidere Park, 6

This inspection was carried out on 23rd January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 10 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Belvidere Park, 6 15/08/06

Belvidere Park, 6 06/07/05

Belvidere Park, 6 02/03/05

Belvidere Park, 6 02/06/04

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 Belvidere Park, 6 6 Belvidere Park Crosby Liverpool Merseyside L23 0SP Lead Inspector Debbie Corcoran Unannounced Inspection 23/01/06 12:30 Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 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 Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 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. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Belvidere Park, 6 Address 6 Belvidere Park Crosby Liverpool Merseyside L23 0SP 0151 284 0023 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 Michael James Geddes Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 3 LD. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 6th July 2005 Date of last inspection Brief Description of the Service: 6 Belvidere Park is a care home registered for three people with a learning disability. The registered provider for this home is Expect, formerly known as Sefton Support Services. This organisation is in the voluntary sector and is a registered charity. The property is owned by Liverpool Housing Trust. The home is located in a residential area in Crosby. The house is in keeping with other properties in the area and is indistinguishable as a residential care home. The home is within walking distance of local shops and Crosby village shopping centre is near by. The home is a large five bed roomed house with two reception rooms and good sized gardens. The home provides two staff 24 hours per day and operates on the principle of ordinary community living. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was unannounced and carried out over a period of 3 hours. During the visit all three of the service users were present and two members of the staff were spoken with. A tour of the home was carried out. Service user plans, health and safety records, medication administration records, staff rotas, menus and other relevant records were examined. What the service does well: What has improved since the last inspection? There was some evidence to indicate that one of the service users is being encouraged to use and develop his independent living skills. Service users now have their own bank account and their personal monies are no longer managed centrally. Therefore service users also have ready access to their own money. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 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. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 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 Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 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 assessed on this occasion. EVIDENCE: Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 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, 9 Service users have a plan of care which reflects their needs and the plans are reviewed and updated regularly. When appropriate communication dictionaries are in place to help the staff to understand the non verbal choices service users are making. When service users are involved in an activity which involves taking risks the risk is assessed and managed. EVIDENCE: Each of the service users has a care plan. The care plans include a record of the service user’s daily and weekly routines and likes and dislikes. The plans also include a developmental plan. The goals set as part of this are realistic. Care plans are monitored / reviewed monthly and are regularly updated . Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 10 Care plans include a communication dictionary which identifies to staff what the service users non verbal communication means. This is a very good tool and means by which staff can understand the non verbal communication of the service users. A number of members of the staff team have worked at the home for a significant number of years and have therefore had the opportunity to get to know the service users individual communication styles. Where a service user is involved in an activity which may present a risk to themselves or others then a risk assessment has been carried out and this includes information on how to manage the risk. The risk assessments are fairly detailed and comprehensive. Risk assessments are monitored on a monthly basis and are regularly reviewed. A risk taking and risk management policy are in place at the home. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 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, 14, 15, 16, 17 Service users are encouraged to use and develop their skills and make choices. Two of the three service users are not being supported with leisure or community activities on a regular basis and the variety of activities service users are supported with could be increased. Service users are not always offered a varied or healthy balanced diet. EVIDENCE: Each of the service users has a development plan which identifies how to support the service user to develop their skills and identifies future goals which the service user needs support to achieve. Service users are encouraged to make choices and each of the service users has a communication dictionary. This assists staff in understanding the non verbal communication used by the service users. Staff support the service users in maintaining family links and friendships as appropriate. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 12 Daily records for each of the service users were examined in order to assess the amount of community access the service users are having. The records checked covered the months of October, November, and January (notes for December were not available). These indicate that one of the service users is regularly supported to go out walking and shopping. However there is little evidence that the other two service users are being supported in pursuing leisure activities or in community access in general on a regular basis. The variety of activities which service users are supported with could also be improved upon. Records showed that one of the service users has really enjoyed a number of activities but this person has not been supported to try any of these again. The manager must review the current arrangements for supporting the service users with leisure activities and community access and ensure that the home is meeting the needs of the service users in this area. An appropriate amount of food was available at the home. Where a service user requires a special diet this is clearly recorded. Service users likes and dislikes in food are recorded in their plans. Menu records for the past couple of months and for the week prior to this inspection were checked. The menu for the past week was poor in terms of the variety of food offered and there was little evidence of healthy meals for that period. The manager must review all menus and ensure that the service users are offered a healthy, well balanced diet which includes fresh foods. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 13 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): 18, 19, 20 Service users are supported by a staff team who know their personal care needs and preferences. Service users are supported to remain healthy. Medication records are not being maintained accurately and this may leave service users and staff vulnerable to mistakes when medication is being administered. EVIDENCE: Information on the needs of the service users with their personal care is recorded in their care plan. It has been reported that there are no restrictions on the times that service users are supported with having a bath or going to bed etc.. and the service users are reported to use non verbal communication to indicate that they want support with these tasks. Each of the service users has an action plan relating to their health care needs. This includes target and actual dates for health checks and these are up to date. There is evidence in service user’s files that relevant health professionals are referred to as appropriate. Records indicated that the service users are regularly supported to attend health related appointments and that staff have followed up concerns appropriately. Where a service users requires support with a specific health condition there is information on the condition and guidelines are in place for how to support the service user. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 14 The home has a medication policy. Records are maintained of medication received and administered and there is a system for stock checking medication on a daily basis. The medication stock record is incorrect for some medications. The manager must ensure that staff are aware of how to complete these records accurately and the manager should audit the records to ensure that they are accurate. Information relating to medication and the side effects of these is clearly recorded. Guidelines for the administration of as required medication are in place. These must be reviewed for one of the service users as staff have administered ‘as required’ medication incorrectly and may have followed the medication procedures relating to another matter. Medication administration records were not accurate as there were some gaps in signatures and some signing in advance of administering medication. All information relating to the service user’s medication should be updated when there is a change in medication. Staff must also ensure that prescribed medication is stored appropriately at all times. Staff have been provided with medication training. The inspector recommends that staff are provided with further training in the administration of medication. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 15 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 Policies, procedures and practices are in place which aim to prevent an abusive, neglectful or issue self harm from occurring. Systems are in place for dealing with allegations of abuse and staff have received training in the protection of vulnerable adults. EVIDENCE: The home has a complaints procedure which is time scaled appropriately and includes details of the Commission. A comments, complaints and suggestions notice is also available in the home along with a complaints leaflet. The complaints procedure should be in a more service user friendly format or the procedure should have been explained to service users. The home has a protection of service users policy and a whistle blowing policy. There is also a policy on physical intervention and aggression towards staff. All accidents or injuries are recorded and there is a procedure in place for reporting these. Staff have been provided with protection of vulnerable adults training. The home has a policy on the management of service user’s money and financial affairs. Each of the service users now has their own bank account and the service users’ personal monies are no longer held centrally and therefore service users have ready access to their own money. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 16 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, 25, 26, 30 The home is generally well presented, homely and clean. Service users bedrooms are personalised with their own belongings and can be locked for their privacy. Health and safety precautions are taken and all relevant safety checks are up to date. Risk assessments on the environment need to be updated to reflect changes in the home. EVIDENCE: The home is in keeping with other properties in the area and is indistinguishable as a residential care home. The house is spacious and has two large lounge areas. Furnishing, fittings and décor are of an appropriate standard and lend to a homely feel. The exterior of the home is in need of repainting. Service user’s bedrooms are furnished and decorated to an appropriate standard with the exception of one room which is in need of redecoration. Service users have a lockable space in their bedroom and bedroom doors are fitted with override locks. Safety glass has now been fitted in one of the service user’s bedrooms following a risk assessment and requirements given at previous inspections. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 17 The home was presented as clean and hygienic. Policies and procedures are in place in relation to; health and safety, control of infection, food safety and hygiene, food safety and nutrition. Staff have received training in a number of core health and safety related issues. A gate had been fitted to the landing area in response to a change in needs of one of the service users. This may no longer be required and if not should be removed. If the gate is going to remain in place then this should be as a result of a risk assessment. Steps at the rear of the house have been determined to be a risk to service users and are no longer in use. This information should be included in the environmental risk assessment for the home. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 18 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): These standards were not assessed on this occasion. EVIDENCE: The inspector did not have access to staff records on this occasion. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 19 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, 42 The home does not currently have a registered manager. Health and safety practices are adopted to ensure the well being of service users and staff. However, some of these practices need to be reviewed. There are some quality assurance processes but these need to be developed. EVIDENCE: A new manager has been appointed at the home since the previous inspection. This person must make an application to the Commission to be registered manager. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 20 Staff have received training in health and safety issues and this includes training on moving and handling, fire safety, first aid, food hygiene and health and safety. The home has a number of policies and procedures which aim to ensure the health and safety of service users and staff and these include policies on health and safety, first aid, fire safety, food safety, medication, COSHH, control of infection. Cleaning products were not being stored safely at the time of the inspection, This was a concern which was also identified at the previous inspection and it was pointed out to a member of staff on duty. Equipment safety checks and gas and electricity certificates were all up to date and available for inspection. Risks assessments are in place in relation to the environment and safe working practices. This should be updated to include the gate on the landing if this is to remain and the entrance steps at the rear of the house. Records showed that fire safety checks are not being carried out regularly. The last fire alarm check was dated 2.12.05 The quality assurance process at the home needs to be developed to ensure that the service users and their representatives are given the opportunity to feedback on the service. It has been reported that Expect Ltd has carried out a quality assurance survey across the organisation. There is no indication that this has included the service user or their representatives from this home. Regular unannounced monthly visits are carried out by one of the management team at Expect. Reports on these visits are forwarded to the Commission on a monthly basis. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 21 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 x 3 x 4 x 5 x 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 2 25 2 26 3 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 x 33 x 34 x 35 x 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 3 x LIFESTYLES Standard No Score 11 x 12 2 13 x 14 2 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 x 2 x 2 x x 2 x Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 22 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA37 Regulation 8 Requirement The registered person must ensure an application for registration of the manager is made to the Commission. Medication administration records must be maintained accurately at all times. Staff must administer ‘as required’ medication in line with written guidelines. All medication must be stored appropriately. All staff must be provided with medication training. All hazardous substances must be stored safely. Risk assessments must be updated to reflect changes. The registered person must review the frequency of fire safety checks. Service users must be offered a well balanced, wholesome and varied diet. The registered person must review service user’s opportunities for leisure and community activities and provide a copy of this review to the Commission. Timescale for action 22/03/06 2. YA20 13 (2) 22/02/06 3. 4. 5. 6. 7. 8. YA20 YA42 YA42 YA42 YA17 YA14 13 (2) 13 (4) (a) 13 (4) (b) 23 4 (c) (v) 16 (2) (i) 16 (2) (m) 22/04/06 22/02/06 22/04/06 22/03/06 22/04/06 22/04/06 Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 23 9. 10. YA25 YA39 23 (2) (d) 24 One of the service user’s bedrooms must be redecorated. A system for quality assurance should be introduced which includes seeking the views of service users and relevant others. The results of this should be published. 22/05/06 22/05/06 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. 2. Refer to Standard YA1 YA24 Good Practice Recommendations Information should be produced in appropriate formats whenever possible. The exterior presentation of the home needs attention. Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 24 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 Belvidere Park, 6 DS0000005248.V280863.R01.S.doc Version 5.1 Page 25 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!