Inspection on 05/04/07 for Breckside Park Residential Home

This inspection was carried out on 5th April 2007.

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 but made no statutory requirements on the home.

Other inspections for this house

Breckside Park Residential Home 06/11/09

Breckside Park Residential Home 17/09/08

Breckside Park Residential Home 03/11/06

Breckside Park Residential Home 17/05/06

Breckside Park Residential Home 15/11/05

Breckside Park Residential Home 20/07/05

Breckside Park Residential Home 01/02/05

Breckside Park Residential Home 13/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME MIXED CATEGORY MAJORITY OLDER PEOPLE Breckside Park Residential Home 10 Breckside Park Anfield Liverpool Merseyside L6 4DL Lead Inspector Debbie Corcoran Key Unannounced Inspection 5th April 2007 10:00 X10029.doc Version 1.40 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 Breckside Park Residential Home DS0000025331.V333792.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 Older People and 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. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Breckside Park Residential Home Address 10 Breckside Park Anfield Liverpool Merseyside L6 4DL 0151 260 6491 F/P 0151 260 6491 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) Mr Keshav Khistria Mrs Kirti Khistria Care Home 26 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (3), Old age, of places not falling within any other category (21), Physical disability (2) Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To accommodate six (6) named persons under the age of 65 years in the overall number of twenty six (26). 3rd November 2006 Date of last inspection Brief Description of the Service: Breckside Park is a registered care home providing personal care for up to 26 residents who are over the age of 65 years. The home has been granted variations to the registered status to provide the care and support to named people who are under the age of 65 years. The home is situated in the Anfield area of Liverpool and is close to parks, shops and public transport routes. Communal space within the home consists of 2 lounges, a dining room and a large conservatory. The home has 26 single bedrooms five of which have an en-suite WC. The home benefits from a large enclosed rear garden and further garden areas to the side and front aspects of the home. The current fee for residing at Breckside Park is £307.20 per week. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This visit to the home was not announced beforehand and took place over a period of approximately 7 hours. The majority of residents were met throughout the day and a number of residents were spoken with on a one to one basis. A tour of the premises was carried out and this included all areas of the home. Records were examined and these included assessment information and care plans for a number of the residents, medication records, staff files, staff training and health and safety records. The manager had provided written information on the home to the Commission before the visit was carried out and some of this information has also been used as evidence for completion of the inspection. In addition to this, questionnaires were sent to residents and their relatives and information gained from these has also been used to support the conclusions of the inspection. What the service does well: The findings of the inspection were positive and residents who were spoken with gave good feedback about all aspects of the home. Resident’s comments included “I am very pleased with the treatment I receive”, “I am very happy with the care I get” and “this is not a home, it is my home, and I am made to feel at home within it”. New residents are only admitted to the home following an assessment of their needs. This is to ensure the home has the appropriate information so as to determine if the person’s needs can be met at the home. New residents are invited to visit the home before deciding whether or not to move in. Each of the residents has a care plan which provides staff with information on how to meet the persons needs. The care plans include information on how to support the residents with their needs in lots of different areas including their personal care and maintaining their hygiene, health, emotional well being, physical care needs, moving and transferring needs, diet and nutritional needs. The quality of food and meals was described as “good” and residents have the choice of a variety of wholesome home cooked food. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 6 Residents are well supported with their health needs. Residents are supported to see a GP or nurse when appropriate and feedback from residents was that staff are good at responding to their health care needs. Staff have been provided with some good training opportunities and further training is planned for the near future. What has improved since the last inspection? There have been many improvements to the service since the last inspection. The home owner was required to provide the Commission with an improvement plan to describe how the home would be improved. During this visit it was evident that many areas of the improvement have now been met and the majority of requirements and recommendations made at the last inspection have been met. There have been further improvements to the care planning for residents. Care plans include all relevant information and are being reviewed on a monthly basis. Where a resident needs support with a health issue this is recorded in their care plan along with information on how to meet the person’s needs and there are further records to show that the care plan has been implemented. A particularly good example was noted where a resident who has a number of health related issues has been well supported and referred to relevant professionals for advice and support. The practices and procedures for the receipt, storage and administration of medication have further improved and medication is now safely managed and administered. Staff have been provided with training in supporting people who have diabetes. There have been some improvements in the home environment since the last inspection and all areas which were identified as in need of attention have been addressed. This has included; redecoration of a number of resident’s rooms and new carpeting has been fitted in the hall and ground floor corridor. There has also been improvement to the cleanliness of the home and the practices in place to control infection. The home has a new manager who started in post approximately 2 months prior to the visit. The running of the home is now also being overseen by an area manager. The service has improved in many areas since the introduction of the new management arrangements. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 7 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management and Administration Scoring of Outcomes Statutory Requirements Identified During the Inspection Older People (Standards 1–6) (Standards 7-11) (Standards 12-15) (Standards 16-18) (Standards 19-26) (Standards 27-30) (Standards 31-38) Adults 18 – 65 (Standards 1–5) (Standards 6, 9, 16 and 18–21) (Standards 7, 15 and 17) (Standards 22–23) (Standards 24–30) (Standards 31–35) (Standards 8, 10 and 37–43) Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 6 (Older People) and Standards 1 – 5 (Adults 18 – 65) are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. (YA NMS 1) Each service user has a written contract/ statement of terms and conditions with the home. Each Service User has an individual contract or statement of terms and conditions with the home. (YA NMS 5) No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Prospective Service Users’ individual aspirations and needs are assessed. (YA NMS 2) Service users and their representatives know that the home they enter will meet their needs. Prospective Service Users know that the home they choose will meet their needs and aspirations. (YA NMS 3) Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Prospective service users have an opportunity to “test drive” the home. (YA NMS 4) Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. 6. The Commission considers Standards 3 and 6 (Older People) and Standard 2 (Adults 18-65) the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s needs are assessed before they move to the home and information on the needs of the residents is attained from relevant professionals when possible. This is to ensure that the persons needs can be met at the home. Residents are invited to visit the home and spend time there before deciding whether or not to move in and residents are provided with a copy of the terms and conditions of their residency. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 10 EVIDENCE: There has been a significant improvement in the home’s referrals and admissions practices since the last inspection. The manager now ensures that pre admissions assessments are carried out before any resident is admitted to the home. Assessment information was looked at for three recently admitted residents. An assessment of needs was in place for each of these residents. These were carried out by the manager of the home. The manager also attains assessments and care plans from relevant professionals for example from care managers and nursing staff. This information is attained so as to determine what the prospective residents needs are and whether or not these can be met at the home. Each resident has a signed contract which sets out the services and facilities provided at the home. Standard 6 is a key standard to be assessed however the home provides long term care only and does not provide intermediate care. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 (Older People) and Standards 6, 9, 16, 18 –21 (Adults 18-65) are: 7. The service user’s health, personal and social care needs are set out in an individual plan of care. Service Users know their assessed and changing needs and personal goals are reflected in their individual plan. (YA NMS 6) Also Service Users are supported to take risks as part of an independent lifestyle. (YA NMS 9) Service users’ health care needs are fully met. Service Users physical and emotional health needs are met. (YA NMS 19) Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service Users, retain, administer and control their own medication where appropriate and are protected by the home’s policies and procedures for dealing with medicine. (YA NMS 20) Service users feel they are treated with respect and their right to privacy is upheld. Service Users rights are respected and responsibilities recognised in their daily lives. (YA NMS 16) Also Service Users receive personal support in the way they prefer and require. (YA NMS 18) Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The ageing, illness and death of a Service User are handled with respect and as the individual would wish. (YA NMS 21) 8. 9. 10. 11. The Commission considers standards 7, 8, 9 and 10 (Older People) and Standards 6, 9, 16, 18, 19 and 20 (Adults 18-65) are the key standards. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each of the residents has care plan and these are sufficiently detailed to direct staff in how to meet the person’s needs. Residents are well supported to remain healthy and staff refer for medical assistance appropriately. Procedures for the receipt, storage, administration and recording of medication are good. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 12 EVIDENCE: A sample of resident’s records were examined in order to assess the care planning in place for residents. Care plans are appropriately detailed and are easy to read and follow. The care plans provide information on meeting the resident’s needs in areas such as; their mental and psychological health, physical health, occupation, social, emotional, promoting safety, promoting communication and social and leisure needs. The care plans also include a longer term plan which aims to develop an aspect of the residents skills or develop their quality of life. The care plans had been reviewed and updated on a regular basis. Some of the care plans examined had been signed as agreed by the resident concerned. Risk assessments are carried out when a resident is thought to be at risk of harm from any given activity. For example with transferring or if they are at risk from a lack of nutrition. Residents records show that they are well supported with their health needs. Residents are supported to see a GP or nurse when appropriate and feedback from residents was that staff are good at responding to their health care needs. A good example of this is that a number of residents have diabetes and records show that they are being well supported to manage this. District nurses visit the home on a regular basis and this is being recorded. Staff had recently been provided with training in diabetes and a resource pack on diabetes is now available. There was a particularly good example provided which showed that the care and support provided to one of the residents has included referring the person to a number of health professionals and resources and the quality of life of this particular resident is felt to be improving as a result. The medication receipt, storage and administration was checked in general and in some detail for three of the residents. The checks showed that medication practices have improved and medication is now managed safely. Medication is reported to be only administered by staff who have been provided with medication training and who hold a certificate for this. The majority of medication is provided in blister packs. Residents were asked if staff are respectful to them and whether their privacy is maintained. All residents who were asked this said that it was. A number of residents choose to spend time on their own and following their own routines and this is well respected. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 13 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 (Older People) and Standards 7, 11– 15 and 17 (Adults 18-65) are: 12. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service Users have opportunities for personal development. (YA NMS 11) Also Service Users are able to take part in age, peer and culturally appropriate activities. (YA NMS 12). Also Service users engage in appropriate leisure activities. (YA NMS 14) Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service Users are part of the local community. (YA NMS 13) Also Service Users have appropriate personal, family and sexual relationships. (YA NMS 15) Service users are helped to exercise choice and control over their lives. Service Users make decisions about their lives with assistance as needed. (YA NMS 7) Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. Service Users are offered a healthy diet and enjoy their meals and mealtimes. (YA NMS 17) 13. 14. 15. The Commission considers standards 12, 13, 14 and 15 (Older People) and Standards 12, 13, 15 and 17 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged to use the local community when they have the skills to do this independently. There is room for further improvement to the variety and frequency of activities for residents to ensure that residents social and recreational needs are met. Residents are encouraged to maintain their independence and exercise choice. A choice of home cooked food is provided to the residents. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 14 EVIDENCE: Residents are encouraged to use the local community when they have the skills to do this independently and a number of the residents come and go from the home as they choose. There has been some improvement in the level of indoor activities for residents over the past year but there continues to be room for improvement. The home’s area manager reported that there will be a new programme of activities introduced in the near future. Recent activities include sing along, bingo, knitting, dancing and art and crafts. A number of residents choose to spend their time in their own company and this is well respected. One of the residents had a birthday party the day before the visit. Some of the residents were talking about the party and they seemed to have really enjoyed it. A number of examples could be seen of how residents are encouraged to exercise choice and control and maintain their independent living skills. Residents are reported to make daily choices such as when to get up, go to bed and have a choice of meals. Residents are encouraged to maintain their skills and maintain their links with the local community. The majority of the residents are well able to express their views and therefore contribute to decision making within the home. Resident’s meetings have been introduced and are continuing to develop. All residents are given their post directly, residents are encouraged to manage their own medication when possible and to manage their own money when possible. The standard of food and meals provided at the home is good. Many resident surveys were returned to the Commission and these all included good feedback on the meals provided. The main meal of the day is served at lunch time and the cook prepares home cooked food from fresh ingredients. The meal served during the inspection appeared appetising and residents said that they had enjoyed it. Residents are served refreshments regularly throughout the day. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 15 Complaints and Protection The intended outcomes for Standards 16 – 18 (Older People) and Standards 22 – 23 (Adults 18-65) are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service Users feel their views are listened to and acted on. (YA NMS 22) Service users’ legal rights are protected. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Service users are protected from abuse. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) The Commission considers standards 16 and 18 (Older People) and Standards 22 and 23 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Policies, procedures and practices are in place for dealing with complaints and for aiming to protect residents from abuse or neglect. Residents are supported by staff who have received training in adult protection. EVIDENCE: The home has a complaints procedure in place. An outline of this is available in the porch to inform residents and visitors of how to make a complaint. Since the last inspection visit there have been two complaints made directly to the commission. These have been investigated and concluded satisfactorily. Residents are aware of how to make a complain or air their grievances and one resident commented “I would immediately go to see the manager who will deal with my complaint straight away” another resident said “I would just tell Lynn, she’d sort things out”. The home has an adult protection policy which identifies that an allegation of abuse should be referred to relevant agencies for example Social Services, the Police and the Commission. The majority of the staff team have been provided with abuse training, this should be extended to include new staff. A member of Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 16 staff who was asked about how they would respond to an allegation of abuse was able to provide an appropriate answer. A record of accidents and incidents is maintained. These records were checked and it was evident that there were some patterns to the frequency and type of accidents for a number of residents. The manager was advised to carry out a regular audit / analysis of accidents and incidents in order to identify possible areas of changing needs of the residents and changes require to their support. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 17 Environment The intended outcomes for Standards 19 – 26 (Older People) and Standards 24 – 30 (Adults 18-65) are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) Service users have access to safe and comfortable indoor and outdoor communal facilities. Shared spaces complement and supplement service users’ individual rooms. (YA NMS 28) Service users have sufficient and suitable lavatories and washing facilities. Service Users toilets and bathrooms provide sufficient privacy and meet their individual needs. (YA NMS 27) Service users have the specialist equipment they require to maximise their independence. (YA NMS 29) Service users’ own rooms suit their needs. Service Users’ own rooms suit their needs and lifestyles. (YA NMS 25) Service users live in safe, comfortable bedrooms with their own possessions around them. Service users’ bedrooms promote their independence. (YA NMS 26) Service users live in safe, comfortable surroundings. Service Users live in a homely, comfortable and safe environment. (YA NMS 24) The home is clean, pleasant and hygienic. The home is clean and hygienic. (YA NMS 30) The Commission considers standards 19 and 26 (Older People) and Standards 24 and 30 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24, 26 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The presentation and cleanliness of the home is improving and the residents are benefiting from a safe, increasingly well maintained and hygienic home environment. EVIDENCE: Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 18 The home provides care for up to 26 residents over 3 floors of accommodation. The home has 2 lounges, a dining room and a large conservatory. The home has 26 single bedrooms five of which have an en-suite WC. The home has a large well maintained and enclosed garden to the rear and further garden areas to the side and front. A tour of the premises was carried out and this included all areas of the home. The communal lounges are reasonably maintained and welcoming. One of these was being redecorated at the time of the visit. The home has aids and adaptations for those residents with mobility needs. There is access to the front of the property via a ramp but there is then a step for access to the house. There is also ramped access at the rear of the home. All areas of the home, which were identified as in need of attention at the last inspection, have been addressed. This has included; redecoration of a number of resident’s rooms and carpets have been replaced in areas across the home. It was reported that there is a programme for the refurbishment and maintenance of the home and there should be continued improvement to the environment. The home was presented as clean and infection control practices have improved since the last inspection visit. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 19 Staffing The intended outcomes for Standards 27 – 30 (Older People) and Standards 31 – 35 (Adults 18-65) are: 27. 28. 29. Service users needs are met by the numbers and skill mix of staff. Service users are supported by an effective staff team. (YA NMS 33) Service users are in safe hands at all times. Service Users are supported by an effective staff team. (YA NMS 32) Service users are supported and protected by the home’s recruitment policy and practices. Service Users benefit from clarity of staff roles and responsibilities. (YA NMS 31) Also Service Users are supported and protected by the home’s recruitment policy and practices. (YA NMS 34) Staff are trained and competent to do their jobs. Service Users individual and joint needs are met by appropriately trained staff. (YA NMS 35) 30. The Commission considers standards 27, 28, 29 and 30 (Older People) and Standards 32, 34 and 35 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Care staff were noted to be available at all times to support residents and to spend time with the residents. Staff are trained in health and safety skills. However there is room for improvement to the number of staff who are qualified in care so as to ensure that residents are supported by a more qualified work force. Staff recruitment and selection practices have improved so as to protect the residents from potential abuse, however there were examples whereby these have not been sufficiently tight. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 20 EVIDENCE: The home is staffed by three members of care staff through the day and evening. Residents said that staff spend time with them and staff seem to be available to meet the needs of the residents in a timely way. All residents have a designated key worker. Staff have been provided with training in adult protection, fire safety, moving and handling, first aid, food hygiene and diabetes. The manager must review the training provided to new staff so as to ensure they have the skills required to meet the needs of the residents safely. For example, staff who are providing moving and transferring support to residents must be provided with moving and handling training so as to ensure that they protect both the residents and themselves from the risk of injury. At the time of the visit there were no staff qualified to an National Vocational Qualification (N.V.Q) level 2 in care. The manager reported that all staff are now enrolled for this and some are enrolled for level 3 in care. In order to meet the national minimum standards the registered person should aim for 50 of the staff team to attain an N.V.Q. Staff recruitment practices and procedures were checked by examining the staff file for 3 of the newest recruited members of staff. It was evident in the employment of one member of staff that the practice for attaining refernces was poor and the information provided in at least one reference gave no indication as to the relationship of the referee to the candidate, no date and no indication that the references had been verified. This fails to protect residents from potential abuse. The manager reported that this person was employed before they took over the management of the home and they are more vigilant in ensuring all appropriate checks are in place. Criminal records bureau checks and staff identification were in place for all new staff. Staff induction needs to be developed to ensure that all staff are provided with a structured induction which meets the National Training Organisation specifications. Staff meetings are taking place on a regular basis. These provide a good opportunity for staff to be provided with information and to discuss the service provided and the needs of the residents. Residents gave positive feedback about the staff including “staff are very friendly and helpful. I feel the staff make it feel that it is my own home”. Another resident said “the staff are lovely, they would do anything for you”. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 21 Management and Administration The intended outcomes for Standards 31 – 38 (Older People) and Standards 8, 10, 23, 37 – 43 (Adults 18-65) are: 31. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from a well run home. (YA NMS 37) Service users benefit from the ethos, leadership and management approach of the home. (YA NMS 38) The home is run in the best interests of service users. Service Users are consulted on and participate in, all aspects of life in the home. (YA NMS 8) Also Service Users are confident their views underpin all selfmonitoring, review and development by the home. (YA NMS 39) Service users are safeguarded by the accounting and financial procedures of the home. Service Users benefit from competent and accountable management of the service. (YA NMS 43) Service users’ financial interests are safeguarded. Service Users are protected from abuse, neglect and self-harm. (YA NMS 23) Staff are appropriately supervised. Service Users benefit from well supported and supervised staff. (YA NMS 36) Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. Service Users know that information about them is handled appropriately, and that their confidences are kept. (YA NMS 10) Also Service Users rights and best interests are safeguarded by the home’s policies and procedures. (YA NMS 40) and (YA NMS 41) The health, safety and welfare of service users and staff are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (YA NMS 42) 32. 33. 34. 35. 36. 37. 38. The Commission considers standards 31, 33, 35 and 38 (Older People) and Standards 37, 39 and 42 (Adults 18-65) the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35, 36, 38 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home does not have a registered manager. There are no systems for checking the quality of the service provided to residents. The system for Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 22 managing resident’s monies has improved but remains insufficient to account for all of the residents monies appropriately. Staff are being provided with supervision to guide them in their practice. Policies, practices and procedures are in place to safeguard the health, welfare and safety of service users and staff. EVIDENCE: A new manager was appointed to the home in January 2007. The home does not have a registered manager and this is in breach of the Care Standards Act 2000 and The Care Home Regulations 2001. The appointed manager reported that she is intending to apply to the Commission for registration as manager. The manager does not hold a relevant qualification. The manager did report that she has enrolled to undertake a relevant qualification. The home does not have a system for quality assurance. The registered person is required to adopt or produce a quality assurance system and this should include surveying the residents and their representatives on the quality of the service. Feedback from this process should then be published and distributed. It is also recommended that an annual development plan is produced which reflects aims and outcomes for residents. The registered person is managing resident’s monies. Records for this were checked and found to be appropriate for some but not all of the residents. There have been improvements to the systems for this but these need to be developed further so as to ensure the records are clear and account for all monies received by residents and all monies given to residents. Staff records and discussions with staff show that staff are being provided with one to one supervision meetings. The manager should review the frequency of these meetings. Health and safety checks were examined. The manager must ensure the fire alarm is tested on a regular basis and must record the outcome of this. In addition to this the manager is required to review the frequency of the testing of water temperatures with particular attention to communal bathrooms. The manager should carry out a risk assessment for safe working practices and this should be reviewed on a regular basis. All other health and safety records and checks which were looked at were found to be up to date. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 3 4 X 5 X 6 X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 ENVIRONMENT Standard No Score 19 3 20 X 21 X 22 X 23 X 24 3 25 X 26 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No Score 31 2 32 X 33 2 34 X 35 2 36 3 37 X 38 2 Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 24 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 OP31 Regulation 8 Requirement Timescale for action 05/06/07 2. OP28 19 (1) 3. OP33 24 4. OP38 13 (4) 5. OP38 23 (4) 6. OP38 13 (4) The registered person must ensure an application for registration of a manager is made to the Commission. (b) The registered person must ensure that staff do not commence employment prior to receipt of all relevant pre employment checks. The registered person must establish and maintain a system for reviewing and improving the quality of care provided at the home. (c ) The registered person must ensure that water temperatures are checked on a regular basis and the outcome of these checks must be recorded. The registered person must ensure that fire alarm tests are carried out on a regular basis and the outcome of these must be recorded. (c ) The registered person must carry out a risk assessment for all safe working practices. 05/05/07 05/06/07 05/05/07 05/05/07 05/06/07 Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 25 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. 3. 4. Refer to Standard OP12 OP18 OP30 OP35 Good Practice Recommendations Residents should be offered opportunities to be involved in a greater range of activities and in community access. The manager should carry out a regular analysis of accidents and incidents. A staff training plan should be developed linked to ensuring staff can meet the needs of the residents. The registered person should develop the system for recording residents monies. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Breckside Park Residential Home DS0000025331.V333792.R01.S.doc Version 5.2 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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