Inspection on 05/06/08 for Burden Road (43)

This inspection was carried out on 5th June 2008.

CSCI found this care home to be providing an Adequate service.

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 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Burden Road (43) 17/07/07

Burden Road (43) 28/09/06

Burden Road (43) 09/12/05

Burden Road (43) 31/05/05

Burden Road (43) 06/01/05

Burden Road (43) 16/06/04

Burden Road (43) 31/01/04

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 27/09/2008.

CARE HOME ADULTS 18-65 Burden Road (43) 43 Burden Road Moreton Wirral CH46 6BG Lead Inspector Lorraine Farrar Unannounced Inspection 5 & 6 June 2008 1.40 DS0000018971.V363526.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 DS0000018971.V363526.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. DS0000018971.V363526.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Burden Road (43) Address 43 Burden Road Moreton Wirral CH46 6BG 0151 678 9962 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) burdenroad@c-i-c.co.uk www.c-i-c.co.uk Community Integrated Care Manager post vacant Care Home 3 Category(ies) of Learning disability (3) registration, with number of places DS0000018971.V363526.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1 The home is registered for a maximum of 3 service users to include: *up to 3 service users in the category of LD (Learning Disability) 17 July 2007 Date of last inspection Brief Description of the Service: 43 Burden Road provides support and accommodation for three adults who have a learning disability. The home is run by Community Integrated Care (CIC) Ltd. They are a national organisation who provide a range of care services across the country. Staff are available twenty four hours a day to support the people who live at 43 Burden Road. The house is a detached property in a residential area of Moreton, close to local shops, transport and facilities. Accommodation is provided over two floors. Everyone living there has their own bedroom. There are two bedrooms and an adapted bathroom on the ground floor. In addition there is a small dining kitchen and large lounge. On the first floor there is a second smaller lounge, an office and third bedroom. Outside there is some parking and gardens. It currently costs between £375.95 and £456.10 a week to live at the home. However the health authority also contributes to current costs. Therefore fees for anyone new moving in may be higher. DS0000018971.V363526.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. We gathered information for this inspection in a number of different ways. We carried out an unannounced visit to the home on the 5 June 2008. This took place over 3.35 hours and included reading records and looking at the building. We visited the home again on 6 June 2008 for 2.5 hours to meet the manager and look at staff records. We spent time looking at the support the people living at 43 Burden Road receive. This included looking at the support they get with their daily lives, care plans, medication, money, activities and environment. We met the three people living at 43 Burden Road and with three members of staff including the manager. Any information the Commission for Social Care Inspection (CSCI) has received since the last big inspection of 43 Burden Road in July 2007 is also taken into account in writing this report. Before our visit we sent out survey forms to the home. Two members of staff completed these and their replies helped us with planning our visit and in writing this report. The manager completed a questionnaire we sent before our visit. Information from this was again used by us to plan this inspection and in writing this report. An easy to understand summary of this report is available. If you would like to see a copy please ask staff working at 43 Burden Road. What the service does well: The staff who work at 43 Burden Road have a good understanding of the people living there and the ways in which they communicate. They respond positively to non-verbal requests from people and ensure that routines in the house are flexible to meet both people’s needs and choices. It is clear that the people living there feel comfortable with staff and are confident that they will respond positively to any requests they make. DS0000018971.V363526.R01.S.doc Version 5.2 Page 6 The people living at 43 Burden Road receive support to get out and about in their local community. This support is provided both on a 1-1 basis and also in small groups and enables peoples to take part in activities of their choosing. Support is provided to help people to access healthcare appointments and to monitor their health. This helps quickly identify and act upon any issues that arise. Regular checks are made on the safety of the building and equipment to ensure that the house is a safe place to live in. There are aids and adaptations around the house to support people with their personal care and their mobility. Everyone living at 43 Burden Road has their own bedroom, which has been personalised to suit their needs and choices. What has improved since the last inspection? What they could do better: The way in which peoples money is managed and spent on their behalf by the organisation is not as clear or robust as it needs to be in order to ensure people’s financial interests are safeguarded and expenditure is always made in their individual best interests. The garden would benefit from regular maintenance in order to ensure it does not appear neglected and to ensure that is can be easily used by the people living there. Quality assurance systems could be improved to ensure they are based on facts rather than statements. This will help to ensure that where DS0000018971.V363526.R01.S.doc Version 5.2 Page 7 improvements to benefit the people who live there are noted, plans can be put into place to improve the service 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. The summary of this inspection report can be made available in other formats on request. DS0000018971.V363526.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 DS0000018971.V363526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Sufficient information is given to and obtained about anyone thinking of moving into the home. This ensures 43 Burden Road is the right place for the person to live and that their needs can be met there. EVIDENCE: All the people who live at 43 Burden Road have lived there for many years; therefore the support offered to people thinking of moving into the home could not be practically assessed. However there is a policy in place from the organisation for introducing new people to the service and the manager was able to explain how this works in practice. Before anyone is offered a place to live at the home, a full assessment of their needs and choices would be carried out. They would also be offered the opportunity to visit the home, meet with staff and the people living there and stay overnight if they wanted to. An information brochure about the service is also available to tell people about the services and support they can expect. This helps everyone to decide if 43 Burden Road is the right place for the person to live and if their needs and choices can be met there. DS0000018971.V363526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The individual needs and choices of the people living at 43 Burden Road are identified so staff can support them to meet those needs and choices. EVIDENCE: Individual care plans and files are available for the three people living at 43 Burden Road. A basic care plan file contains plans with the headings of need / problem / objective of the plan and staff / nursing instruction. These sheets are clearly for general use throughout the organisation. Although they had been personalised to the people living at Burden Road and contained some basic guidance as to how to support them, the wording ‘nursing instruction’ could be misleading. In addition the description of a persons support needs as a ‘problem’ could be seen as negative. DS0000018971.V363526.R01.S.doc Version 5.2 Page 11 These plans contained brief details of the support the person prefers. However discussions with staff revealed a lot more information. For example one member of staff was able to clearly explain how the person prefers to be supported with their personal care, how they show they want support and the things they can do independently as well as the things they require support with. Each person at the home also has an essential lifestyle plan in place. These use pictures to aid people’s understanding and contain a lot more information about the person. This includes the things they like and dislike, how they communicate and how to support them effectively in a way they prefer. Staff told us that the first files are used as a quick reference for unfamiliar staff. However as the people who live at Burden Road do not use verbal forms of communication, it is equally important that those supporting them know about their personalities and choices as well as their basic support needs. All care plans had been reviewed regularly and updated as changes to people’s support needs and choices became apparent. Everybody’s care plan contained a series of risk assessments relating to them. These covered areas such as their environment, going out and personal care. Information was recorded regarding the identified risk and the actions that needed to be taken to minimise that risk. These had been reviewed regularly and were up to date. These assessments help to identity risks to the person and actions that can be taken to support them to stay safe whilst still engaging in everyday activities In discussions staff were able to explain the way in which the people living there make decisions and how they communicate this. For example records showed and staff confirmed that the people are able to decide for themselves when they want to get up and go to bed. During our visit one person indicated to staff that he wanted a drink and staff responded positively to his request. At a later time he indicated to staff that he wanted to go out by leading them to the back door. Again staff responded quickly to his choices and supported him with this. DS0000018971.V363526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The people living at 43 Burden Road are supported so they can live a lifestyle of their choice. EVIDENCE: Discussions with staff and records in the home showed that the people living at 43 Burden Road receive support to get out and about regularly in their local community. For example in the past few days one person had been out for a walk, to the cinema, shopping and for a drive. In addition people were seen to spend their time at home either in the company of others or in private as they chose. The people were seen to seek out the company of staff when they wanted and to be comfortable in their presence and confident that any requests for support with drinks or leisure activities would be acted upon. DS0000018971.V363526.R01.S.doc Version 5.2 Page 13 Staff were able to explain the different things the people enjoy doing and that each person regularly gets 1-1 support from a member of staff to go out. This was further confirmed via records kept in the home. The 1-1 support provided enables people to spend time away from their home engaging in activities that they particularly enjoy as well as spending time at home or out and about with the other people they live with. For example one person likes to go shopping to the supermarket regularly and to the cinema. Records showed support is provided to enable him to do these things. Routines in the home are flexible with people getting up and going to bed when they wish, having meals and drinks at times that suit them and spending their time doing the things they enjoy. The small dining table in the kitchen provides room for only three people to eat together, which could lead to staff standing in the kitchen rather than sitting and socialising with people. However two members of staff explained that as routines are flexible, people get up and have breakfast when they are ready, therefore this is not an issue in a morning. In addition often one person is eating out with staff support and one of the people living there often chooses to eat in the lounge, again with staff support. This flexibility of routines helps to ensure that people are able to enjoy their mealtimes at their own pace. Records of meals served in the home showed that a variety of meals are served in order to offer people as much choice as possible. However although one person’s health action plan advises that people should eat 5 portions of fruit and vegetables daily, it is not clear from records whether this is offered. Over one five day period from 2 June 2008 only two portions of fruit and vegetables are recorded as being offered. Staff explained that they do provide these. However in order to ensure that people are offered a diet that will support them to stay healthy, a record of actual meals served should be made in sufficient detail. DS0000018971.V363526.R01.S.doc Version 5.2 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. The personal care needs and choices of the people living at 43 Burden Road are identified so they are supported to meet these by the regular staff team. EVIDENCE: Staff we spoke with were able to explain the support people need with their personal care and how they prefer this to be provided, as well as their preferred daily routines. For example a member of staff explained that one person likes to wear pyjamas at home during the day and he is supported to so this and to get changed again later if he is going out. Another member of staff explained that the people who live at the home show when they wish to go to bed and get up and that this is supported by staff. Records showed this support is offered, with one person choosing to go to bed at times varying between 9.30 pm and 12.15 am. During our visits it was clear the people living at 43 Burden Road had received support with their personal care. Staff were seen to continue to provide this during the day and to ensure the people had privacy whilst doing so. DS0000018971.V363526.R01.S.doc Version 5.2 Page 15 Information is recorded in people’s care records about the support they require with both their personal and health care and records showed that their health is monitored. When needed staff support them to make and attend health appointments. Care plans contain brief information regarding the support people need with their personal and health care, along with risk assessments to identity and deal with any risks in these areas. Some further information is contained in people’s Essential Lifestyle Plans. However as identified elsewhere in this report the use of different sources of information regarding people’s support choices as well as their needs may result in unfamiliar staff not supporting people in a way they need and prefer. Staff who support people with their medication have received training in dealing with medication. A locked cabinet is provided to store medication correctly and we saw this being used during our visit. Clear records are kept of medication received into the home and given to the people living there. We looked at samples of the medication held and records relating to it and found them to be accurate. The clear systems in place for dealing with medication, along with staff training, help to reduce the risk of mistakes occurring that could impact on people’s health. DS0000018971.V363526.R01.S.doc Version 5.2 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. Clear systems are in place within the home for dealing with any concerns or complaints that arise. However people’s finances are not always dealt with in a way that ensures they are financially safeguarded. EVIDENCE: Information about how to raise a concern or complaint is made available to the people living at 43 Burden Road in an easy to understand format. This is good practice as it helps to increase the opportunities for people using the service now and in the future to have a better understanding of the ways in which they can raise any concerns. A relative of one of the people living there has previously confirmed to us that she is aware of the complaints procedure and had telephone numbers she could use to raise any concerns she may have. Staff said in their comment cards and in discussions with us that they are aware of the action they need to take if anyone raises concerns regarding the service. They receive training in recognising and dealing with safeguarding adults and a member of staff spoken with was clear about the action she would take if these occurred. The organisation has polices in place for dealing with complaints and safeguarding issues and these provide guidance for staff. However during our site visit a copy of the local authority safeguarding procedures could not be found. It is important that these are readily available in the home in order to DS0000018971.V363526.R01.S.doc Version 5.2 Page 17 ensure staff have access to clear information about the actions they should and should not take to protect people. It was identified at our previous inspection of 43 Burden Road in July 2007 that the support provided to people in managing their money was not always recorded well enough to ensure it was managed in their best interests. Records were available in the home that showed people receive the personal allowance part of their benefits in a timely fashion and their bank accounts are managed safely. However the three people living there contribute to a shared vehicle and have done so since February 2005. No records were available that detailed the yearly running costs of each vehicle and to show why each person is contributing the amount of £35. 43 weekly. The organisation has provided blank financial plans to use and these were available in everyone’s care plan. However, although signed by managers the plan had not been fully completed to evidence the decision making process for each person. This process if completed correctly and fully would clearly show whether a shared vehicle with the weekly contribution was in the person’s best financial interests or not. It is a matter of concern that the organisation has not taken action to ensure people’s money is managed in their best interests and have failed to comply with a requirement from us to do so. We have written to the home separately from this report to request clear records of how they intend to evidence the support they have provided to people with this matter and ensure it does not re-occur. Samples of records and amounts of money held within the home for the people living there were checked and were correct. DS0000018971.V363526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. 43 Burden Road provides a clean, comfortable home for people to live in. However the home would benefit from some redecoration and attention to the gardens in order to further improve the appearance of the house. EVIDENCE: 43 Burden Road is a detached house in a residential area of Moreton. It is similar to other houses in the local area and does not stand out as a care home. Inside the house provides everyone with their own bedroom, which has been personalised to suit their needs and tastes. For example some of the people have a double bed in their room and a sofa so that they can comfortably sit in there if they wish to do so. DS0000018971.V363526.R01.S.doc Version 5.2 Page 19 There is an adapted bathroom downstairs with walk in shower, grab rails and a bath chair to help people with their mobility and personal care. Shared space consists of a small dining kitchen, a large lounge which provides plenty of space for people to relax in, and a smaller upstairs lounge. Outside there is some parking for the house vehicle, and side gardens. New windows and doors have been fitted to the downstairs of the house, which will make the home quieter and warmer to live in as well as more secure. However the outside of the house looked shabby during the two days we visited. The front garden gate was missing and lawns were overgrown and full of weeds. A hanging basket at the front door contained plants that had died, adding to the general shabby appearance of the outside of the house. The manager told us that she had contracted local gardeners to mow the lawn. However at the time of our visits the long grass may have prevented people sitting out and enjoying their gardens comfortably. Since our last visit a risk assessment has been carried out on the use of fire doors inside the home. As a result these are now left open at certain times. This gives the people who live there more independence in their own home as they can now walk freely through it rather than having to wait for someone to open a door for them. During our visits we observed the people using communal areas of the house freely and clearly feeling comfortable within their home. All areas of the house were clean and tidy during the site visit. However the kitchen is beginning to look shabby with some parts of the sealant peeling and parts of the worktops chipping. The lounge, whilst large and comfortably furnished, is dark in appearance and may benefit from some redecoration to provide a brighter room for people to sit in. A laundry room provides suitable washing and drying facilities with protective clothing and equipment in place to help prevent an outbreak or spread of infection. DS0000018971.V363526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 People who use this service experience good outcomes in this area. We have made this judgement using available evidence including a visit to this service. Staff are thoroughly vetted before they start work at the home and receive training so they can support the people who live at the home safely and well. EVIDENCE: It was clear during both our visits that the people living at 43 Burden Road feel comfortable with the staff who support them. Discussion with three of the staff working there and observations of how they interact with the people showed that staff have a good understanding of their individual support needs and choices and are able to understand their non verbal methods of communication. Several of the staff hold a care qualification (NVQ) and another member of staff is working towards this. This helps to ensure staff are aware of current good practice in the area of care and how to support people safely and well. One member of staff said in their comment card that, “Our training covers everything and is now good”. Records showed that staff undertake a variety of training to help them support people. This includes areas of health and safety DS0000018971.V363526.R01.S.doc Version 5.2 Page 21 such as food hygiene as well as good practice in care such as health action planning and managing conflict. New staff undertake a long induction to care services that equips them with basic skills and knowledge in how to support people safely and well. Records showed that before anyone is appointed to work at 43 Burden Road a series of checks are carried out. These include obtaining written references and checking with the Criminal Records Bureau (CRB) and register of people unsuited to work with vulnerable adults. These checks help to ensure the people living there are safe and that staff are suitable to support them. DS0000018971.V363526.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42 People who use this service experience adequate outcomes in this area. We have made this judgement using available evidence including a visit to this service. 43 Burden Road is generally managed safely. However systems for quality assurance are not always robust enough to identify, plan and implement improvements that would benefit the people living there. EVIDENCE: The manager of 43 Burden Road is experienced in managing care services for adults with a learning disability and holds qualifications in this area. She has applied to the Commission to become registered as the manager of the home. This process helps to ensure the suitability of managers to manage a particular care service. DS0000018971.V363526.R01.S.doc Version 5.2 Page 23 During our visit the manager displayed a good awareness of the support needs and choices of the people living in the home. There are several systems in place within 43 Burden Road to check the quality of the service they provide and plan improvements. These include regularly reviewing and updating care plans, risk assessments and other paperwork. In addition the home manager and service manager complete a 6 monthly quality monitoring form. The last form was completed in April 2008. However this contained statements rather than facts and evidence. For example the document stated, “I have a good choice of menu” and “I am involved in the recruitment process”. No actual evidence that proved these statements was included. In order to provide a full overall picture of the service and identify clear areas for improvement the service needs to include evidence as to how they reach conclusions in their quality monitoring. This will enable them to plan future improvements to the service that can be measured and evaluated for the benefit of the people living there. As previously explained within this report, records relating to decision-making around people’s finances were not fully completed. A robust quality assurance system would, if correctly used, identify this and provide an opportunity for the service to implement improvements. Similarly the self-assessment form completed before this inspection was not detailed as to future plans for the service that could be assessed and measured for their effectiveness in improving the service to benefit the people living there. Records and certificates showed that regular checks are carried out on the building and equipment. This includes checking electrical appliances, the gas supply and regular fire checks. These checks help to ensure that the home is a safe place to live and work in. DS0000018971.V363526.R01.S.doc Version 5.2 Page 24 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 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X DS0000018971.V363526.R01.S.doc Version 5.2 Page 25 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 YA23 Regulation 13(6) Requirement A full assessment of the way in which people’s money is managed by the organisation must be carried out. This must include information on: • • • the amount of money they receive a rationale as to why they contribute towards a shared vehicle the costs of this vehicle and how the contribution is worked out. Timescale for action 18/08/08 This will help to ensure people’s money is safeguarded. This requirement is repeated from the previous inspection in July 2007. DS0000018971.V363526.R01.S.doc Version 5.2 Page 26 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 YA6 Good Practice Recommendations The system of using two separate care files for each person should be reviewed. This should take into account the possible impact on people of unfamiliar staff possibly missing information about the person’s choices and lifestyle. The amount of fruit and vegetables people are offered should be recorded and monitored. This will help to ensure people are supported to eat a diet that will support their health. A copy of the local authority safeguarding adult’s policy should be obtained and all staff familiarised with its contents. This will help to ensure staff have guidance readily available if needed, to deal with any safeguarding issues that may arise. A system should be put into place to ensure the garden is maintained at all times to an acceptable standard. This will help to make the home are more attractive place to live and ensure the people living there can make use of their garden when they wish to do so. The way in which quality assurance reviews are carried out should be reviewed. This should include providing evidence to support views recorded and ensuring systems are robust enough to note and act upon any shortcomings within the service as well as plan future improvements. 2 YA17 3 YA23 4 YA24 5. YA39 DS0000018971.V363526.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection North West Region CSCI Preston Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 DS0000018971.V363526.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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