Inspection on 22/05/06 for Blackburn Drive, 13

This inspection was carried out on 22nd May 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Blackburn Drive, 13 10/06/08

Blackburn Drive, 13 24/07/07

Blackburn Drive, 13 21/03/06

Blackburn Drive, 13 08/12/05

Blackburn Drive, 13 15/11/04

Blackburn Drive, 13 27/07/04

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 Blackburn Drive, 13 13 Blackburn Drive Halewood Liverpool Merseyside L25 0QF Lead Inspector Ms Lorraine Farrar Unannounced Inspection 22nd May 2006 01: 30 Blackburn Drive, 13 DS0000021459.V293195.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 Blackburn Drive, 13 DS0000021459.V293195.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. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Blackburn Drive, 13 Address 13 Blackburn Drive Halewood Liverpool Merseyside L25 0QF 0151-486-2054 0151 486 2054 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) www.c-i-c.co.uk. Community Integrated Care Mrs Mary McGibbon Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service User to Include up to 2 LD Date of last inspection 21st March 2006 Brief Description of the Service: Blackburn Drive provides support and accommodation for two adults who have a learning disability and some additional physical disabilities. The home is operated by Community Integrated Care (CIC) who provide staff, budgets and support, the building itself is owned by Liverpool Housing Trust who are responsible for maintaining the structure of the premises. The home is a detached bungalow in a residential area of Halewood and fits in well with other houses in the nearby area. Outside there is a front garden with some parking and an enclosed back garden with small patio. Inside the home provides two single bedrooms, an office, lounge, dining room, one bathroom and kitchen, there is also a small extension at the back, which is used for some storage and laundry facilities. The home has some adaptations, including, a walk in shower, hoist and ramps fitted to the front and back of the house. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information for this inspection was gathered in a number of different ways. This included reading records and looking at the building. ‘Case tracking’ was used as part of the visit to the home. This involves looking at the support a person gets from the home including their care plans, medication, money and bedroom, time is also spent meeting with the service user and with staff about how they meet the persons needs. Both of the people living in the home were case tracked as part of this inspection. Discussion also took place with the relative of a service user. Any information the Commission for Social Care Inspection (CSCI) has received since the last inspection about the home is also taken into account. The home is requested to contribute information to the inspection by completing a pre-inspection questionnaire, however this was not received from Blackburn Drive. What the service does well: There is a good policy in place within the home for introducing new service users and assessing their needs, this helps to make sure the home can meet the persons needs and helps the person make an informed choice about living there. Care plans in the home are well written and updated and provide a good basis for planning and delivering support to service users with their personal and healthcare and meeting their individuals needs and choices. Staff have a good understanding of service users needs with their personal and health care and provide support to meet these. Individual risk assessments are in place for service users and staff spoken with were able to explain the risk and the action they take to reduce these. Service users receive a variety of meals and the support they require at mealtimes. The home has suitable policies in place for dealing with any complaints or adult protection issues that arise. There is sufficient space within the home for service users, staff and visitors. With the exception of the bathroom, the home is clean, comfortable and nicely furnished and decorated. There are sufficient staff on duty to meet service users needs, the home provides a stable staff team who have a good understanding of service users personalities, needs and choices. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 6 The home has exceeded the national standard for care homes with regard to staff qualifications. This states that at least 50 of the team should hold a care qualification (NVQ). At Blackburn Drive 100 of the team have achieved this. Most health and safety checks are carried out at regular intervals. What has improved since the last inspection? What they could do better: As identified at previous inspections the home need to upgrade the bathroom to an acceptable standard. The organisation also need to provide a risk assessment for the self-closing fire doors and act upon the findings of this, in order to minimise the risk identified to service users, staff and visitors. The organisation need to be more open regarding the way in which they manage service users monies and provide explanations on file as to how this is managed and why. At present this cannot be fully inspected in order to establish that it is managed safely and appropriately. They also need to look at the systems in place for communication between the home and organisation and improve upon these. This will help to make sure that messages and information are fully given, received and understood. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 7 Quality assurance systems that include the views of service users where possible and their relatives must be carried out regularly and the results of these made available for inspection and for service users and their relatives. These reviews should provide a basis for planning within the home and organisation on maintaining and improving standards. The home needs to make sure that regular, recorded checks are carried out on water and fridge temperatures, this will ensure that both are operating safely for service users. The organisation needs to make sure that they communicate with the CSCI and meet requirements that are given for the safety and well being of service users within the timescales given. Outstanding requirements from previous inspection relate to, the environment, management of monies, quality assurance of the service and the safety of service users. The home should compile a training plan for all individual staff and the team, this will help identify training that is due for renewal and ensure training suitable for meeting service users needs is identified and provided. 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. Blackburn Drive, 13 DS0000021459.V293195.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 Blackburn Drive, 13 DS0000021459.V293195.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. The home has an appropriate policy in place for introducing and assessing new service users before they move in. EVIDENCE: Both of the people who live at Blackburn Drive have lived there for many years, therefore the assessment process for new service users could not be practically assessed. The home has a policy in place for introducing new service users. This states that a full assessment must be carried out before the person move in and that trial visits will be offered. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 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 the following standard(s): 6, 7 & 9 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. There are clear care plans and risk assessments in place for service users covering all aspects of their daily life. Staff in the home are aware of service users choices and support them in daily decision making, however this aspect of the support provided needs to be further developed. Not all records of service users monies managed by the organisation are made available for inspection. EVIDENCE: Care plans are in place for both of the people living at Blackburn Drive, these are reviewed and updated regularly. Plans cover and provide information on areas of the person life, including the support they need with mobility, mealtimes, personal and health care, relationships and safety. Information about how the person communicates and their daily routines and preferences is also recorded. Individual risk assessments are in place looking at Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 11 The people who live at the home do not communicate verbally. Staff spoken with were able to give examples of how they communicate with service users to find out what they want and do not want to do, and had a good understanding of individuals likes, dislikes and choices. The opportunity for service users to make decisions and their needs known, relies to some extent on the staff team understanding and responding to their non-verbal communications. It was therefore recommended at this inspection that the home includes a section in care plans on how to support the person to make decisions, increase their decision making skills, and understand the way this is communicated by the service user. A requirement was given at the last two inspections of the home that the organisation must arrange a meeting with the CSCI to discuss their management of service users monies. This was because records of service users finances held in the home were confusing and out of date with some records not available and it was not possible to establish whether service users monies are managed safely. These records were again not available in the home for inspection, however the organisation have contacted the CSCI and arranged a date to meet with them and discuss management of service users monies and the requirements of the CSCI in this area. However it was not possible to fully inspect the way in which service users finances are managed and ensure they are managed both safely and appropriately. It has been a recommendation of previous inspection that the home support service users to access appropriate advocacy services. The Manager advised that she has had difficult with this but has obtained some contact information and intends to contact them. This will help the home to establish, as far as possible, service users choices. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15 & 17 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home supports Service users to access leisure and occupational facilities in accordance with their choices, to maintain relationships and to eat a balanced diet with support at mealtimes when needed. EVIDENCE: On the day of the inspection both service users went out to the local safari park, staff explained that they enjoy this activity and hold season tickets so that they can visit regularly. As well as going out together, some 1-1 support is provided to service users. One service user is supported to attend a local college and to walk to the shop once a week with their keyworker, purchase a music magazine and on return home look at the magazine with staff before watching the accompanying musical DVD. The other service user receives support to go out for a drive or walk, as they prefer. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 13 Staff have worked with a service users relative to increase the opportunities offered for one service user to get out and about more. As a result a weekly, community sensory room has been found and both service users attend once a week. The home have also found a swimming pool that provides the aids to support both service users and a date in June 06 has been booked, with a view to regular visits if this is a success. A relative explained that although initially slow, they are pleased with the progress made in this area. Records in the home for service user’s were looked at from 1st May 2006, these showed that they had spent time at home listening to music, looking at photos and having pamper sessions and had visited relatives, been out for walks and drives, attended the sensory room, been shopping, out for lunch, to college and to the safari park. The home are using a car that has for some time been identified as unsuitable for service users needs and staff comfort. However an order form for an adapted vehicle was seen and the Manager advised they anticipated delivery within 2 weeks. Records in the home showed that service users relatives are able to visit at any time and that the home are supporting one service user to visit their parents. A recent meeting was held with a relative to work together to plan and provide appropriate support for the service user. The home are sending regular updates to the relative to make sure they are involved and updated regarding the service users lifestyle. The homes statement of purpose says that, ‘ family should be involved and contribute to the care of their relative’ and there is a policy in place for staff to support service users with relationships and sexuality. Service users have the opportunity to meet people without a disability via their use of local shops and leisure facilities. The home holds a budget for food shopping and uses local shops and supermarkets. The Manager explained that sometimes staff carry out a ‘main’ shop and other times a service user goes to the supermarket, depending on their plans and choices on the day. Records showed that both service users are supported to go to a local farm shop for fresh fruit and vegetables every Saturday. The menu is decided daily depending on service users plans for the day. Records of this showed that service users are offered a choice of meals and that the home will make different meals for each service user depending on their needs and choices. Staff were spoken with were all able to explain the support they offer to service users at mealtimes, with regular drinks and in monitoring their intake. The Manager explained that due to the high level of support service users’ need, staff do not eat with them at mealtimes but do sit at the table to provide 1-1 support and at other times have a snack or drink with them. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 14 There were sufficient stocks and variety of foods in the home and these were stored correctly. Encouraging service users with healthy eating was discussed during the inspection, the manager explained that they provide fresh fruit juice vegetables and fruit and stocks of these were available. It was recommended that the home record on menus when these are offered so that they can monitor whether they are providing sufficient amounts of these to each service user. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 15 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 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service Staff have a good understanding of service users support needs and personal care is provided in keeping with their needs and choices. The home supports service users’ to access regular and specialist health care checks and appointments. Medication is well managed within the home. EVIDENCE: Care plans contain clear information about the support the person needs with their health and personal care and staff were able to explain the support they provide to each person. Records showed that the home provides a good level of support to service users in accessing healthcare. This includes regular healthcare checks such as the dentist and optician and more specialist appointments such as the physiotherapist and orthopaedic clinic. Both service users were well presented and a relative explained that they are satisfied with the personal care offered to the service user. At the last inspection requirements were given that staff needed to attend training in moving and handling people and in medication, this training has now been undertaken by all members of staff. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 16 Medication is stored in a locked cabinet which was seen to be well organised with clear systems in place and records kept of stock checks and medication given. The home has a medication policy in place and all staff have received training in dealing with medication and use of steisolid diazepam. Records and stocks of medication for both service users were checked and were in order. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 17 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 quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service The home has suitable polices and procedures in place for dealing with complaints and adult protection and this information is available to service users and relatives. Service users monies are managed safely within the home, however the organisation do not provide sufficient information about their management of service users monies, therefore it is not possible to make a judgement on the safety of their practices. EVIDENCE: The home has a copy of Community Integrated Care’s (CIC) complaints procedure, which states how the complaint will be dealt with and the timescale for doing so. There is a book in the home for recording complaints received about the service, although none had been received. Information about how to make a complaint is made available in the service user guide and statement of purpose. Copies of the CIC and local authority, adult protection procedures are also available and staff had training in adult protection in March 2006. As explained in the individual needs and choices section of this report, there are no clear records maintained within the home of how the organisation manage service users monies. Records and amounts of service users monies held by the home were checked and were in order. Staff files evidenced that the home carries out suitable checks prior to appointing new members of staff and at regular intervals. Care plans contain information about how to support service users who self – harm and staff were able to explain the actions they take to lessen the risk to the service user. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 18 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, 27, 28, 29 & 30 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service Overall Blackburn Drive provides a suitable, clean, homely and well maintained environment with sufficient space for service users, staff and visitors. The exception to this is the bathroom, which is not of a standard found in most domestic homes. There are suitable procedures and practices in place for dealing with infection control. EVIDENCE: Blackburn Drive is well placed for accessing local amenities. The home is based in a residential area of Halewood, accommodation is in a 3 bedroom bungalow, which fits in well with other domestic homes in the area. With the exception of the bathroom, the home was warm, clean and nicely decorated with a homely atmosphere. Shared space within the home consists of a lounge, separate dining room, kitchen, office, laundry and enclosed back garden. These rooms are comfortably furnished and decorated and have a homely atmosphere. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 19 Outside there is a large back garden with patio. Parking is available on the front drive or on the road outside. Throughout the home there is sufficient space for service users, staff and visitors to use. Service users have their own bedrooms, which provide enough space for them to manoeuvre and have their personal possession around them. It has been identified at the previous 2 inspection of the home that the bathroom is not of a standard acceptable in most domestic homes. It appears very cold and uninviting with no form of constant heating available. Décor and fittings appear old fashioned, there are four different types of tiles used on the walls, the shower chair is rusty, the floor tiles appeared to have ground-in grime, the sealant around the bath is rotting and the windows are single glazed adding to the lack of warmth. A requirement was previously given to the home that this room be refurbished to an acceptable standard by 30th May 2006. Although this work had not been carried out, the manager contacted the CSCI in May 06 to advise the housing association had visited the home, agreed to carry out the work and put this out to tender, further evidence of this was available in the homes diary. Therefore an extended date for complying with the requirement was given at this inspection. There are a number of aids and adaptations available to support service users with their mobility, this includes, ramps, walk in shower, grab rails and a hoist. The home has an industrial washing machine with sluice facility and provides, disposable clinical waste bags, gloves and aprons, the manager advised that staff receive training in infection control via their induction and care (NVQ) training. Laundry facilities are in a small room off the kitchen, however the home has a policy in place for infection control and suitable practices are followed to minimise any risk of an outbreak of infection. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 20 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): 32, 33, 34, & 35 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Service users are supported by a stable, competent, staff team with sufficient staff on duty to meet their needs. Recruitment practices in the home help to ensure service users are safe. Staff receive training in basic areas of care to help them support service users, however this should be planned and reviewed regularly to endure it meets service user and staff needs. EVIDENCE: Staff in the home have worked hard in recent months to obtain a care qualification (NVQ), with 100 of the team holding a level 2 NVQ, members of staff spoken with were motivated to build on this training and stated they would like to work towards a level 3 NVQ in care. During the inspection staff were seen to interact positively with service users and in discussions it was evident they had a good understanding of how to support service users, ensure their needs are met and their individuality respected and catered for. The staff rota showed that the home provides 2 members of staff during the day with one staff available at night times. Many of the staff working in the home have been there for several years or more and provide a stable team for service users. There are a couple of staff vacancies, the Manager explained and the rota confirmed that these are generally covered by regular bank or agency staff who have become familiar with service users. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 21 The Manager also explained that two staff have been provisionally appointed and are awaiting recruitment checks before commencing work. The organisation has a suitable policy in place for ensuring checks are carried out on new staff to make sure they are suitable to work with service users. Staff files contained copies of Criminal Records Bureau (CRB) checks for staff and evidence that these are re-applied for at regular intervals. Written references, identification and completed application forms are obtained for staff and there is a formal interview process in place. CIC has a training department, which organises training for staff and sends out details of training planned and there is there a structured induction programme for all new staff. Recent training for staff has included, NVQ, moving and handling, medication, protection of vulnerable adults, basic food hygiene and fire training. The diary recorded further training booked, including, learning to train staff (Train the Trainer) and 1st aid. Full records of staff training and a training plan for the team were not available, the manager explained that a staff training plan has been completed, however this was currently with her line manager. It is recommended that an up to date training plan is completed and available in the home for all members of staff and for the team as a whole. This will help to make sure staff are up to date with current practice and that they receive training to help them meet service users individual and collective needs. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 22 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 quality in this outcome area is poor. This judgement has been made using available evidence, including a visit to this service. The home is operated by an experienced, qualified Manager, however the organisation do not always communicate effectively with the home or meet inspection requirements in a timely fashion. There is no evidence that the home carried out regular audits of the service they provide in order to maintain and improve on current standards. Health and safety issues are generally safely managed however here is an identified risk to service users with regards to the self-closing fire doors fitted throughout, the organisation are aware of this risk but have not taken action to minimise or prevent an accident occurring. EVIDENCE: Mrs Mary McGibbon is the Registered Manager of the home. She has many years experience of working with adults with a learning disability and has worked at Blackburn Drive since service users moved in. Mrs McGibbon holds a care and management qualification and through reading records and Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 23 discussion it was evident that she attends training events to maintain and increase her knowledge. She stated that she has a job description from the organisation covering her role in the home. Staff and a relative spoke with during the inspection process expressed concern that communication between the home and the organisations line managers was not as effective as it should be and that this has lead to information not being fully or wholly passed on correctly. Staff advised that the organisations managers do not always respond to queries and a relative explained that there is suspicion of the organisation within the home and that senior managers can be difficult to contact. The organisation must put systems into place for communicating regularly with the staff team and obtaining their views. The organisation do not always meet inspection requirements within the timescales set, with one long standing requirement regarding service users monies still outstanding and 3 further outstanding requirements relating to fire doors, quality assurance and the environment remaining unmet. It was identified at the last inspection of the home in March 2006 that no records of the organisations quality assurance systems were available. A requirement was given that they must establish a system for reviewing the quality of the service and make copies of this review available to the CSCI and in the home for service users and their relatives by 30th June 06. This will help the home to review the service they offer and put plans in place to maintain areas in which they meet or exceed good practice standards and make plans to improve on areas, where needed. At this inspection no evidence of a quality assurance system was available. However the manager explained that these are carried out regularly and she had an appointment with her line manager the following day to complete a quality assurance form. The home state a commitment to diversity and equality within there philosophy of care, stating that no service user will receive less favourable treatment on the grounds of their race, colour, disability, religion, nationality, Political beliefs or sexual orientation. Staff receive training in diversity and equality via their NVQ training. The home had satisfactory records and certificates available for, gas, hoist, electrics, fire alarm, risk of legionella and emergency lights. The fire book evidenced that regular check of fire equipment, tests and training for staff are carried out. During an inspection of the home in December 2005 it was identified that there was a difficulty with the self-closing fire doors. These close automatically but due to service users disabilities this can cause a risk to them or their carer in getting through the door using a wheelchair, the alternative of wedging the door open leads to an increased risk of any fire spreading rapidly through the Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 24 home. A requirement was given that the home must carry out a risk assessment of these doors taking into account the risk to service users of fire and to their mobility and act upon any findings. At the last inspection of the home in March 2006 this requirement had not been met, however evidence was available that the organisations Health and Safety Officer had visited the home and the manager stated that a report of her findings was being prepared. At this inspection the organisation had, again not complied with this requirement. The Manager advised that the organisation plan to fit automatic fire closures to these doors, which would reduce the risk to service users and staff. This requirement has been repeated at this inspection, as the home are still not taking action to minimise identified risks to service users, staff and visitors. The temperature of the hot water in the bathroom was tested by hand during the inspection and was satisfactory. Records of water and fridge temperatures in the home had not been recorded since March 2006. These should be tested regularly to ensure food is stored safely and water temperatures are at a comfortable but safe temperature for service users. Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 25 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 1 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 2 1 X X 2 X Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA27 Regulation 23(2) Requirement The home must arrange for the bathroom to be refurbished to an acceptable standard. This is a requirement of the last two inspections of the home. The home must carry out a risk assessment of the self-closing fire doors and act on any findings. This is a requirement of the last two inspections of the home. All finances relating to the running of the home and individual service users must be maintained within the home. This requirement was previously issued on several occasions. 4. YA39 24 The home must establish a system for reviewing the quality of the service and make copies available to the CSCI and in the home for service users and their relatives. This is a requirement of the previous inspection DS0000021459.V293195.R01.S.doc Timescale for action 30/08/06 2. YA42 13(4)(c) 20/07/06 3. YA43 25 & 20 30/08/06 30/06/06 Blackburn Drive, 13 Version 5.2 Page 27 5. YA42 13(4)(c) 6. YA38 21 The home must test and record temperatures of the fridge and hot water supply at regular intervals. The organisation must put systems into place for communicating regularly with the staff team and obtaining their views. 25/06/06 30/07/06 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. Refer to Standard YA7 Good Practice Recommendations The home should support service users to access an appropriate advocacy service. This is a previous inspection recommendation 2. YA35 The home should compile a training needs assessment and plan for individual staff and for the staff team. The home should include in service users care plans a section stating how they support service users to make decisions and increase their skills in this area. The home should monitor and record all food and drink offered to service users to ensure they are offering a healthy diet in keeping with government guidelines. 3. YA7 4. YA17 Blackburn Drive, 13 DS0000021459.V293195.R01.S.doc Version 5.2 Page 28 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 Blackburn Drive, 13 DS0000021459.V293195.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. 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