Inspection on 06/07/05 for Belvidere Park, 6

This inspection was carried out on 6th July 2005.

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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Belvidere Park, 6 15/08/06

Belvidere Park, 6 23/01/06

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 6 Belvidere Park 6 Belvidere Park Crosby Liverpool, Merseyside L23 0SP Lead Inspector Debbie Corcoran Unannounced 6th July 2005 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 6 Belvidere Park Address 6 Belvidere Park Crosby Liverpool Merseyside L23 0SP 0151 284 0023 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Expect Limited Mrs Michael Geddes Care Home 3 Category(ies) of LD - Learning Disability registration, with number of places 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 3 LD 2. The service should employ a suitably qualified and experienced manager who id ergistered with the CSCI Date of last inspection 2nd March 2005 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.. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 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 three hours. During the visit all three of the service users were present and both 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 in some detail. What the service does well: What has improved since the last inspection? The system for reviewing service users care has been developed in line with good practice. Each of the service users has had a full review of their care at the home as carried out by Social Services and the outcome of these reviews has been positive. There appears to be some increase in the level of social opportunities, certainly for two of the three service users. The first floor bathroom has been completely refurbished. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 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. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 4, 5 A statement of purpose and service user guide is available to provide service users and their representatives with information on the home. Systems are in place for assessing the needs of prospective service users, arranging introductory visits and a trial stay. Each of the service users has a contract with the home. EVIDENCE: The home has a good information pack which includes information on the aims and objectives of the home and the services and facilities provided. This information should also be produced in service user friendly formats. The home has a referral and admissions policy and a policy on introductory visits. There is also a policy on service users plan of care which includes a statement that each service users file will contain a copy of initial assessment documentation. The home has an introductory visits policy which outlines that a trial period is offered to service users. An emergency admissions policy is also in place. Referral and admissions procedures could not be practically assessed on this occasion as there have been no new service users to the home for a number of years and since the introduction of the national minimum standards. Service users records evidenced that each of the service users has had the opportunity of a reassessment of their needs by the relevant Social Services Department. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 9 Each service user has a contract with the home. These are signed appropriately and a copy is kept in the service user’s personal file. The contracts should be produced as accessible to service users as possible. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 9, 10 Service users have a plan of care which reflects their needs and the plans are reviewed and updated regularly. When service users are involved in an activity which involves taking risks the risk is assessed and managed. Personal and confidential information is handled appropriately. EVIDENCE: Each of the service users has a care plan. The plans include a record of the service user’s daily and weekly routines and likes and dislikes. The plans include a section specific to the service user’s health care needs. The plans also include a developmental plan. The goals set as part of this are realistic. Care plans include a communication dictionary which identifies to staff what the service users non verbal communication means. This is a very good tool if used effectively by staff. Care plans are reviewed regularly and a community care review has been carried out with each of the service users. Family members were invited to this as appropriate. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 11 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 have been reviewed appropriately. A risk taking and risk management policy are in place at the home. It was evidenced that all confidential information in the home is maintained securely. The home has a confidentiality policy and expectations on staff in terms of confidentiality are also made clear in the organisations information pack. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 13, 14, 17 Staff support service users to use local facilities and pursue their leisure interests. The level of opportunities for this does not seem to be equitable for all service users. Service users are offered a good variety of food. Staff have the required information to ensure that service user’s special dietary needs are met. EVIDENCE: 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 13 Daily records relating to each of the service users were examined in order to assess the amount of community access the service users are having. These indicate inconsistencies in the level of community access and leisure activities for different service users. For one of the service users the amount of leisure activities was regular and varied, for another service user the amount is fair and for another service user the amount was not great at all. A member of staff reported that the service users would benefit for going out more often but there are some restrictions with transport at the moment. Service user plans include goals for development for each of the service users have been produced and realistic target dates for achieving or working towards these have been set. A good level and variety of food including fresh 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. One of the service users should be encouraged to use his independent living skills in eating whenever possible. This was discussed with a member of the staff team during the inspection. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19, 20 Service users are supported by a staff team who know their personal care needs and preferences. Service users are supported to remain healthy. Medication is handled safely and in accordance with policies and procedures. EVIDENCE: Information on the needs of the service users with their personal care is clearly recorded in their care plan. 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. There is clear evidence in service user’s files that other relevant 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 supporting service users with health related issues as appropriate. 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. A record of all health related issues / appointments is maintained. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 15 The home has a medication policy. Service user’s medication is kept in a lockable space in their own bedroom. Records are maintained of medication received and administered and there is a system for stock checking medication on a daily basis. Information relating to medication and the side effects of these is clearly recorded. Guidelines for the administration of as required medication are in place. Medication administration records were examined and found to be maintained appropriately. The way in which the blister packs are currently being used could be confusing and may lead to an error in administration of medication. The manager should review this. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22, 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. Service users are restricted in access to their money and records regarding service user’s money are not appropriately maintained. 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. An issue identified at previous inspections remains outstanding. This is in relation to service users not having access to their own money. A representative from Expect has explained how they intend to resolve this matter but there are no signs of any development with this at this time. Some of the records of service user’s money are either unavailable or unclear. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 30 The home is well presented, homely and clean. Service users bedrooms are personalised with their own belongings and can be locked for their privacy. Service user’s privacy is not being maintained in all areas of the home. One of the service users may be at risk of injury due to a low level window. Health and safety precautions are taken and all relevant safety checks are up to date. 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. Service user’s bedrooms are furnished and decorated to an appropriate standard. Service users have a lockable space in their bedroom and bedroom doors are fitted with override locks. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 18 An assessment, as carried out by an occupational therapist, has identified that the window in one of the service user’s bedrooms presents as a potential hazard. The registered manager has attempted to address this but to no success to date. A requirement has been given for this to be addressed. 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. The first floor bathroom has been fully refurbished and redecorated since the previous inspection. A large area of damp now needs to be treated and a tap on the bath needs to be repaired. The water temperature in the bathroom was checked and found to be appropriate. One of the locks on the bathroom door should be removed as it is inappropriate. The manager must review the arrangements for maintaining the privacy of service users in using ground floor shower and toilet facilities. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 35, 36 Staffing levels allow for some one to one support for service users. Staff training opportunities are good and staff have received training in some specialised areas. Staff have the opportunity to meet one to one with their manager and to meet as a team on a regular basis. EVIDENCE: 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 20 There are two staff to support the service users at all times throughout the day There is currently a full compliment of staff and staff turnover is low. This results in a stable staff team and service users therefore benefit from consistency of support from staff who know their needs. Service users files evidence that staff have appropriately referred for specialist support and advice to meet individuals needs. Most staff have undertaken core skills training, for example food hygiene, fire safety, first aid, moving and handling. All but one member of the staff team have received medication training. Some members of the staff team have received training in non violent crisis intervention and on supporting people with challenging behaviour. Discussions with a new member of staff confirmed that they have received an induction. The newest member of staff commenced employment approximately six months ago and in this time they have received training in fire safety, food hygiene, health and safety, first aid and the protection of vulnerable adults and induction to care. There is a staff training and development plan as part of the business plan for the home. A member of staff confirmed that they are receiving regular supervision and team meeting are regular. Staff records were not available at the time of inspection to further evidence this. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 41, 42 Practices that promote the health and safety of service users and staff are in place. Service user’s rights are safeguarded by the safe keeping and security of records and all records are up to date and maintained appropriately. EVIDENCE: 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 22 The manager was not available at the time of inspection and therefore some of the above standards could not be assessed. 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 discussed with a member of staff. Records evidenced that fire safety checks are carried out regularly. Risks assessments are in place in relation to the environment and safe working practices. The records kept at the home are in good order, up to date and maintained securely. A record of all accidents, injuries, incidents and complaints is maintained. All records were available for inspection with the exception of staff files as the member of staff on duty did not have access to these. Records regarding service user’s monies need to be maintained appropriately and provide evidence of accountability. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 x 3 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 2 x x 3 Standard No 11 12 13 14 15 16 17 3 x 3 2 x x 3 Standard No 31 32 33 34 35 36 Score x x 3 x 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 6 Belvidere Park Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score x x x x 2 3 x F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 24 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 YA 39 Regulation 23 (2) (a) (n) Requirement All recommendations made as a result of the occupational therapist assessment must be carried out in full. One outstanding issue remains regarding a low level window in one of the service user bedrooms. All hazadorous substances must be stored safely. The area of damp in the bathroom must be treated. The manager must ensure that service users have access to their money as required and all records relating to service users incoming and outgoing monies must be clear and up to date. Timescale for action 6.10.05 2. 3. 4. YA 42 YA 24 YA 23 13 (4) (a) 23 (2) (b) 17 (2) Schedule 4 Immediate 6.10.05 6.10.05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard YA 17 YA 1 Good Practice Recommendations Service users independent living skills should be encouraged and supported at all times. Information should be produced in appropriate formats F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 25 6 Belvidere Park 3. 4. YA 20 YA 14 whenever possible. The way in which staff are currenlty using medication blister packs should be reviewed. All service users should have equality of opportunity to pursue leisure interests and access the community. 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Burlington House, South Wing, 2nd Floor Crosby Road North Waterloo, 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 6 Belvidere Park F53 F03 S5248 6 Belvidere Park V239936 060705 Stage 4.doc Version 1.30 Page 27 - 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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