CARE HOME ADULTS 18-65
Bungalow, The 35 Grosvenor Avenue Crosby Liverpool Merseyside L23 0SB Lead Inspector
Mrs Janet Marshall Unannounced Inspection 24th November 2005 09:30 Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Bungalow, The Address 35 Grosvenor Avenue Crosby Liverpool Merseyside L23 0SB 0151 928 8318 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) North West Community Services (GM) Limited Mr Thomas Robson Ritchie Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. Service users to include up to 3 LD The service should, at all times, employ a suitably qualified and experienced manager who is registered with the CSCI. Date of last inspection Brief Description of the Service: 35 Grosvenor Avenue is a detached bungalow located in a residential area of Crosby. It is situated close to local amenities and all forms of public transport. The home is registered to provide care and support for three people who have a learning disability. There are currently two men in residence. The service provider for the home is North West Community Services. The organisation has other similar homes in the North West region. The house is owned and maintained by LHT a local housing association. The aim of the home is to provide an ordinary lifestyle for the people who choose to live there and to respect their rights and choices. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspection visits are required at the home each year, this was the second. There has been no cause for any visits to the home since the last routine inspection in July 2005. This was an unannounced inspection that took place over 5 hours. A partial tour of the home was conducted. All parts of the home were clean and tidy. Over the past year the home has been made more comfortable for residents following repairs, the replacement of carpets and the redecoration of various rooms. Both residents were at home throughout the inspection during which time they continued with their routines and activities as usual. At intervals throughout the inspection discussion took place with both residents and two members of staff. Their comments and views about their life and experiences at the home were obtained. A selection of care records and other required records were inspected. Records that were examined included residents care plans, Essential Lifestyle Plans (ELPS), daily diaries, medical notes, medication sheets, staff rotas and records of health and safety checks. The registration and insurance certificates showing the correct information were displayed at the home. The requirements and recommendations from the last inspection were discussed and examined. All but one requirement has been met. That requirement from the last inspection was for a record of complaints made by residents to be kept detailing any investigation, action taken and outcome. As there was no evidence to show that this has been done it has again been raised as a requirement as part of this report. What the service does well:
The service has provided each resident with a contract so that they have a statement of terms and conditions of their occupancy. The service provides each resident with a clear individual plan of care, which are reviewed and updated at regular intervals to ensure that resident’s needs are understood and met. Residents are able to access their care plans when they wish. They said that they know what is written about them because they are consulted about their care plans. Records and discussion with residents and staff show that the service ensures that residents are supported to achieve greater independence and that they are consulted on issues that affect their daily life. The service ensures that residents are given choices and are able to move freely around the house so promoting their independence. The service ensures that the privacy and dignity of residents is maintained at all times. Residents said that staff are respectful when helping them with personal care.
Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 6 Over the past year or so improvements have been made to various parts of the home making it more comfortable and attractive for the residents who live there. The home is also clean and tidy. The service carries out regular health and safety checks of the premises, which ensures the safety of residents and staff. What has improved since the last inspection? 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. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 Information about the home has not been improved so that residents can easily access it. All residents have a contract so benefit from having a statement of terms and conditions of their occupancy. EVIDENCE: There have been no new residents admitted to the home since the last inspection. At the last inspection one resident had difficulty understanding some of the wording in the homes information pack. A recommendation was made as part of the last inspection report for the information to be made more accessible to residents. There was no evidence that this has been done therefore it has been made a recommendation again as part of this report. Residents have been provided with a contract/statement of terms and conditions. The contracts are available in resident’s individual files. They set out the services and facilities offered by the home, terms and conditions of occupancy, fees, rights and responsibilities of parties and other issues as outlined in the National Minimum Standards. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 9 & 10 Resident’s benefit from clear individual plans of care that are reviewed regularly. Residents are aware of the content of these plans. Residents are being supported to achieve greater independence and all are consulted on issues that affect their daily life. EVIDENCE: An Essential Lifestyle Plan (ELP) and a care plan for both residents were examined. It is understood that these are being presented into an individual format appropriate to the needs of residents. Each care plan highlights the needs that residents have and include reference to any risks present or issues with respect to behavioural needs. All care plans are reviewed at least every six months although there was evidence in some plans that reviews had been more frequent. Residents and or representatives have signed all care plans. All plans of care are accessible to the staff team with evidence that these are working documents. When not in use these documents are secure but are available for residents and staff to refer to. All other information about residents is also kept securely in the home.
Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 10 Detailed daily records, which outline the progress of each resident, reinforce care plans and these records are linked to specific goals within the plan of care. Daily records show that residents are involved in aspects of life in the home, which is appropriately supported by staff. The service continues to hold staff and resident meetings, which provide the opportunity for residents to contribute to the running of the home. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 Residents are given choices and are able to move freely around the house as part of an independent lifestyle. EVIDENCE: Both residents were seen using all parts of the home. Staff provided the help and assistance as requested to enable residents move around the home. A good sized lounge area and dining room, which is separate to the kitchen, provides residents with a good amount of shared and private space apart from their own bedrooms. Staff were seen offering residents with choices and respecting the decision that they made. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 Personal support is carried out in a sensitive and flexible way to ensure the privacy and dignity of residents at all times. EVIDENCE: Staff support residents with personal care. A resident said that personal care is carried out in his own bedroom and the bathroom he also said that staff are respectful when helping with personal care. Both residents were case tracked. They have available individual plans of care, which identify relevant aspects of health and personal care and plan accordingly. There is good information, which show that residents health care is monitored and that they access the appropriate health care facilities at the required intervals. Mobility needs are well assessed and planned for as well as nutritional requirements. Staff showed a good understanding of the medical, and personal care needs of residents. A district nurse visits the home regularly. Records of the visits are kept. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Concerns rose by a member of staff and a resident were immediately acted upon ensuring that all concerned are protected and safeguarded from potential abuse. Records of a previous complaint made by a resident were not available for inspection. EVIDENCE: During the inspection a resident and a member of staff raised concerns. The concerns were related. The service manager who was immediately notified of the concerns acted promptly and appropriately. During the last inspection records about a complaint made by a resident were unavailable. A requirement was given as part of the last report for all records of complaints made by residents to be kept detailing any investigation, action taken and outcome. Records relating to the complaint could not be located during this inspection therefore this has again been raised as a requirement as part of this report. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 14 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 30 Resident’s benefit from a clean and hygienic home. EVIDENCE: During a tour of the home it was noted that it was clean, tidy and free from offensive odours. Laundry facilities are available. These are separate from food storage and preparation areas. Industrial washing and drying appliances are installed in this area. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 15 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33 & 36 Resident’s benefit from the support of staff who are competent and have a good understanding about the needs of the residents. Regular supervision of staff ensures that they are clear about their roles and responsibilities. EVIDENCE: Staff were observed interacting well with residents. They showed that they have good knowledge and understanding of each persons needs and were patient and caring in their approach. Staff responded to residents in a sensitive and flexible manner. During discussion a member of staff said that they are happy with the level of training provided. A member of staff said the manager is regularly supervising staff on a one to one basis. Supervision records were not seen as they were kept in a secure place and can only be accessed by the manager. A member of staff said that discussions between them also take place daily in addition to regular staff meeting. Supervision of staff ensures that they are appropriately supported and fully aware of their roles and responsibilities. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 16 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39 & 42 The provider is not providing the commission with reports to show that the required monthly visits are being carried out at the home. The necessary checks are being carried out to ensure the health, safety and welfare of residents. EVIDENCE: A member of staff said that a representative for the company visits the home monthly, to interview residents and staff and inspect the premises. It is important that this is done so that to check records and form an opinion of the standard of care in the home. Following the visit the representative writes a report a copy of which must be sent to the Commission. The Commission are not receiving these reports. This must be done in accordance with Regulation 26 of the Care Homes Regulations 2001 Amended (2004). This has been given as a requirement as part of this report. Records showed that regular Health and Safety checks on the environment are being carried out and recorded. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 17 Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 18 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 X X X 3 Standard No 22 23 Score 2 X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 3 3 Standard No 24 25 26 27 28 29 30
STAFFING Score X X X X X X 3 LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X X 3 X X 3 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Bungalow, The Score 3 X X X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 3 X DS0000005434.V269020.R01.S.doc Version 5.0 Page 19 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 YA22 Regulation 22(3) Requirement A record of complaints made by residents must be kept detailing any investigation, action taken and outcome. Quality audit reports must be forwarded onto the commission each month. Timescale for action 24/01/06 2. YA39 26 24/01/06 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 YA1 Good Practice Recommendations The manager should make the homes Statement of Purpose & Service user Guide more accessible to residents. Bungalow, The DS0000005434.V269020.R01.S.doc Version 5.0 Page 20 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
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