Inspection on 21/08/06 for Cambridge

This inspection was carried out on 21st August 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cambridge 18/09/07

Cambridge 13/02/06

Cambridge 22/11/05

Cambridge 08/02/05

Cambridge 21/07/04

Cambridge 29/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME MIXED CATEGORY MAJORITY ADULTS 18-65 Cambridge Road 43/45 Cambridge Road Bootle Liverpool Merseyside L20 9LF Lead Inspector Mr John Mullen Unannounced Inspection 21st August 2006 09:30 Cambridge Road DS0000005259.V302245.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 Cambridge Road DS0000005259.V302245.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. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Cambridge Road Address 43/45 Cambridge Road Bootle Liverpool Merseyside L20 9LF 0151 284 5007 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.peterhouseschool.org Autism Initiatives Simon Michael Thomas Care Home 4 Category(ies) of Learning disability (4) registration, with number of places Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to Include up to 4 (LD) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection 13th February 2006 Date of last inspection Brief Description of the Service: Cambridge Road is a home for the personal care and support for a maximum of four adults with learning disabilities. The home is owned by Autism Initiatives, a voluntary organisation experienced in this field and the registered manager is Simon Thomas. The home’s fees range from £960 to £1275 per week and charges are assessed according to residents’ means. There is an additional charge for toiletries, activities, hairdressing, and other sundry items. The home is situated in a residential area of Bootle within easy access of shopping and general community facilities. The premises consist of two separate houses, each of which accommodates two residents and a central courtyard links these. One house has self-contained accommodation for each resident whilst the other has communal facilities for the other two residents. In addition, the home has two sleep-in rooms to accommodate staff. The home provides twenty-four hour staffing cover from a dedicated staff team led by a registered manager and deputy manager. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced key inspection which took place over two days and included a site visit. The core National Minimum Standards were assessed. Interviews took place with the deputy manager and two care workers. Two residents were interviewed and two family members interviewed by telephone. The home was inspected and a large amount of documents held by the home was seen. What the service does well: What has improved since the last inspection? Since the last inspection some improvements have been made to the premises which have maintained the physical standards of the home. The arrangements for one resident in respect of her medical needs have been improved and good arrangements continued for the medical and health needs of residents generally. Plans for individual residents have been advanced so that future Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 6 placements can be considered. The home has maintained its good record in promoting the individual needs of residents. 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. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home Individual Needs and Choices Lifestyle Personal and Healthcare Support Concerns, Complaints and Protection Environment Staffing Conduct of Management of the Home Scoring of Outcomes Statutory Requirements Identified During the Inspection Adults 18 – 65 (Standards 1–5) (Standards 6-10) (Standards 11–17) (Standards 18-21) (Standards 22–23) (Standards 24–30) (Standards 31–36) (Standards 37-43) Older People (Standards 1–5) (Standards 7, 14, 33 & 37) (Standards 10, 12, 13 & 15) (Standards 8-11) (Standards 16-18 & 35) (Standards 19-26) (Standards 27-30 & 36) (Standards 31-34, 37 & 38) Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 (Adults 18 – 65) and Standards 1 – 5 (Older People) are: 1. 2. 3. Prospective service users have the information they need to make an informed choice about where to live. (OP NMS 1) Prospective users’ individual aspirations and needs are assessed. No service user moves into the home without having been assured that these will be met. (OP NMS 3) Prospective service users’ know that the home that they choose will meet their needs and aspirations. Service Users and their representatives know that the home they enter will meet their needs. (OP NMS 4) Prospective service users’ have an opportunity to visit and “test drive” the home. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. (OP NMS 5) Each service user has an individual written contract or statement of terms and conditions with the home. Each service user has a written contract/statement of terms and conditions with the home. (OP NMS 2) 4. 5. The Commission considers Standard 2 (Adults 18-65) and Standards 3 and 6 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. Cambridge Road has full background material on residents so that work can be planned appropriately. EVIDENCE: An examination of files in the office revealed a large quantity of background material on which the home could base its work in order that it can be planned appropriately. This information was dispersed in two files and the deputy manager confirmed that a more simplified approach will be adopted in the near future. Discussions with staff showed them well aware of the needs of residents and both residents and families contacted felt that the home fully understood these needs so that their placement in the home was appropriate and beneficial. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 9 Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6-10 (Adults 18-65) and Standards 7, 14, 33 & 37 (Older People) are: 6. Service users know their assessed and changing needs and personal goals are reflected in their Individual Plan. The Service Users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users make decisions about their lives with assistance as needed. Service Users are helped to exercise choice and control over their lives. (OP NMS 14) Service users are consulted on, and participate in, all aspects of life at the home. The home is run in the best interests of service users. (OP NMS 33) Service users are supported to take risks as part of an independent lifestyle. The service users health, personal and social care needs are set out in an individual plan of care. (OP NMS 7) Service users know that the information about them is handled appropriately and that their confidences are kept. Service Users rights and best interests are safeguarded by the home’s record keeping, policies and procedures. (OP NMS 37) 7. 8. 9. 10. The Commission considers Standards 6, 7 and 9 (Adults 18-65) and Standards 7, 14, and 33 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. Care planning needs to be changed so that it can be used to direct the work with residents. Residents are encouraged in their independence, including through risk assessments, so that they can lead as full a life as possible. EVIDENCE: An examination of residents’ files found inappropriate care plans in place. The care plans were multiple, relating to individual activities and not giving an overall plan of care and were out of date, with a lack of review so that their continuing relevance is questionable. An interview with the deputy manager confirmed that the home is aware of the deficits in the care planning and that this has been pointed out in the last three inspections, meaning that it needs Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 11 to be resolved urgently. The home is working to a new support plan in the context of a reorganisation of the files generally, so it recognises that an improvement in this area is overdue. Interviews with staff, residents and families revealed a good understanding of work with residents but an interview with one resident, confirmed by an interview with his father, showed that there was only an annual review of his progress, although this was not recorded in the files, which is below the required standard. Interviews with staff, confirmed by interviews with residents, showed that the latter are encouraged to make decisions in the context of their individual capacities so that they have greater control of their lives. Both male residents do their own shopping, as does one of the female residents, whilst one female resident is supported by staff in this area. One female resident cooks with staff support, the other female less so and both men do their own cooking, so they have involvement in the daily routines of the home. Residents choose their own clothes and their own activities, depending on capacity, meaning they have a degree of control over their lives. The male residents are very independent, the females less so, due to their greater level of dependency. An interview with one male resident showed he was very clear about his ability to make decisions and described the staff as “100 ” so that he is both well supported and encouraged to take control over his daily routines. An examination of files showed there were many risk assessments to cover specific activities but no overall assessment so that staff have an easy, accessible document to use. Risk assessments have been reviewed this year but need to be rationalised. An interview with the deputy manager confirmed that the risk assessment process was being re-examined as part of a rearrangement of the files and she accepted that the present system was cumbersome. Interviews with staff found them knowledgeable about residents and aware of the individual risks associated with them. Observation during the inspection showed that residents were being cared for appropriately and safely so that their disabilities were not hindering their lives to any unreasonable extent. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 (Adults 18-65) and Standards 10, 12, 13 & 15 (Older People) are: 11. Service users have opportunities for personal development. 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. (OP NMS 12) Service users are able to take part in age, peer and culturally appropriate activities. 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. (OP NMS 12) Service users are part of the local community. Service users maintain contact with family/ friends/ representatives and the local community as they wish. (OP NMS 13) Service users engage in appropriate leisure activities. 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. (OP NMS 12) Service users have appropriate personal, family and sexual relationships and maintain contact with family/friends/representatives and the local community as they wish. (OP NMS 13) Service users’ rights are respected and responsibilities recognised in their daily lives. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users are offered a (wholesome appealing balanced) healthy diet and enjoy their meals and mealtimes. Service users receive a wholesome appeaing balanced diet in pleasing surroundings at times convenient to them. (OP NMS 15) 12. 13. 14. 15. 16. 17. The Commission considers standards 12, 13, 15, 16 and 17 (Adults 1865) and Standards 10, 12, 13 and 15 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 and 17 Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. The home provides appropriate activities both internally and externally so that residents can pursue their intervests. Relationships are encouraged and daily routines Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 13 devised to maintain links with families and friends and promote independence. Appropriate food is served to encourage a healthy diet although this needs to be recorded in all cases. EVIDENCE: The varying degree of disabilities of residents means that there is an individual approach to education and occupation depending on residents’ needs. One resident is currently seeking a job with a voluntary organisation and, in interview, he confirmed that he is being fully encouraged by staff to do this, which has increased his confidence. Staff will encourage educational and employment opportunities in so far as residents wish and are able to pursue these. One resident attends a day centre twice a week and others are occupied as they so wish so that there is not a rigid approach to this subject. Interviews with staff and evidence from the files confirmed that residents use local facilities as required so that they are more integrated into the community. All have bus passes and use local buses, some with staff support. Two residents regularly use the library and all go to local pubs, so that they are not isolated within the home. Interviews with staff confirmed that the home is well integrated into the neighbourhood and residents are accepted as part of the local community. One resident complained of the noise levels in the area but, otherwise, there was no reported difficulty with the environment. Relatives contacted were happy with the location of the home which has caused no problems for their family members. Interviews with staff and residents, contacts with families and documentation seen confirmed that family contact is encouraged and supported. Families interviewed were very complimentary about the home, which was variously described as “excellent” and “very good”. They also confirmed that staff keep in touch so that they are informed of residents’ progress. Equally, another comment was that the family was “very happy with the care”. The home has a visitors’ room to enable families to stay overnight and one family, in particular, uses this, which enables them to visit more frequently. The inspection also showed that staff support residents to visit families and that friends of residents are encouraged to visit so that family and other links are maintained. A tour of the home showed that residents lock their own accommodation and that their independence is respected throughout. Interviews with residents showed that they felt their privacy was respected and this was confirmed by interaction between staff and residents, which was friendly, appropriate and supportive. Residents also help with the daily routines, although sometimes encouragement is needed in this area, so that they are being encouraged to actively participate in the home. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 14 The home has menus for the female residents, one of whom draws up her own menu plan so that she is fully involved in planning meals. The male residents do not have set menus because they are encouraged to cater for themselves. However, they do not record the food eaten, which means that a full record is not available and this could be a problem in assessing their nutritional needs. An interview with one male resident showed that he was happy to cooperate in this once the reasons were explained. Residents appeared happy with the food on offer and with the support they received in cooking and shopping so that meals and food arrangements generally did not pose a problem in the home. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 15 Personal and Healthcare Support The intended outcomes for Standards 18 – 21 (Adults 18-65) and Standards 8 – 11 (Older People) are: 18. 19. 20. Service users receive personal support in the way they prefer and require. Service users feel they are treated with respect and their right to privacy is upheld. (OP NMS 10) Service users’ physical and emotional health needs are met. Service users’ health care needs are fully met. (OP NMS 8) 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. Service users, where appropriate, are responsible for their own medication and are protected by the home’s policies and procedures for dealing with medicines. (OP NMS 9) The ageing, illness and death of a service user are handled with respect and as the individual would wish. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. (OP NMS 11) 21. The Commission considers Standards 18, 19 and 20 (Adults 18-65) and Standards 8, 9 and 10 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. Support is given appropriately, including in the area of health care and medication, so that residents are cared for positively and safely. EVIDENCE: Interviews with residents and their families confirmed a high degree of satisfaction with the way in which support is given. One family member described the home as “excellent” with “excellent staff”. An interview with the deputy manager confirmed that only minimal personal support is required with the present group of residents, some of whom require encouragement in some instances rather than active help with personal care. One resident is diabetic and is receiving appropriate support from the district nursing service to manage this condition. The home operates a key worker system and residents Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 16 were very positive about the staff of the home who they felt cared for them in a pleasant and appropriate manner. Observed interaction between staff and residents during the inspection was excellent so that there was a pleasant atmosphere within the home. There are a minimal amount of rules and residents are encouraged to act independently within the context of their disabilities so that they lead as full a life as possible. An examination of files confirmed that health care needs are monitored and promoted as required with full documentation present as required. All attend the same general practitioner and receive an annual check up so that there is an active approach to promoting good health. On the day of the inspection one resident was unwell and was escorted to see her general practitioner. Lists of visits to relevant personnel including dentists, chiropodists and opticians are recorded so that an up to date record is maintained. Examination of medication records showed that medicines are being administered correctly and that some elements of self-medication are taking place, which is in accordance with good practice. Medicines are appropriately stored so that safety is maintained. Interviews with a new member of staff confirmed that she has not received medication training but she does not administer medicines on her own so that correct procedures are followed. The deputy manager stated other staff have received medication training and some records seen confirmed this, so ensuring that safety is maintained in this area. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 17 Concerns, Complaints and Protection The intended outcomes for Standards 22-23 (Adults 18-65) and Standards 16-18 & 35 (Older People) are: 22. 23. Service users feel their views are listened to and acted on. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted on. (OP NMS 16) Service users’ are protected from abuse, neglect and self-harm. Service users legal rights are protected. (OP NMS 17) Also Service users are protected from abuse. (OP NMS 18) Also Service users financial interests are safeguarded. (OP NMS 35) The Commission considers Standards 22-23 (Adults 18-65) and Standards 16-18 and 35 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 Quality in this outcome area is good . This judgement has been made using available evidence including a visit to this service. The home acts on residents’ views in a positive and open manner. EVIDENCE: The home has a complaints’ policy, although it does not contain the name and address of the Commission, which is required for a registered service. An examination of the book recording complaints revealed no complaint since the 1st February 2005, which confirmed the positive findings of the inspection. Discussions with residents and their families revealed no complaint about the service but, on the contrary, a very complimentary view about the home, reflecting a high opinion of Cambridge Road. One relative interviewed was particularly complimentary about the fact that the home will work through problems with residents rather than seek to move them if challenging behaviour occurs. The evidence from interviews was that the home will act quickly and appropriately to deal with any concern by residents or families alike so that these can be dealt with openly and appropriately. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 24 – 30 (Adults 18-65) and Standards 19-26 (Older People) are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users live in a safe, well-maintained environment (OP NMS 19) Also Service users live in safe, comfortable surroundings. (OP NMS 25) Service users’ bedrooms suit their needs and lifestyles. Service users own rooms suit their needs. (OP NMS 23) Service users’ bedrooms promote their independence. Service users live in safe, comfortable bedrooms with their own possessions around them. (OP NMS 24) Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Service users have sufficient and suitable lavatories and washing facilities. (OP NMS 21) Shared spaces complement and supplement service users’ individual rooms. Service users have access to safe and comfortable indoor and outdoor communal facilities. (OP NMS 20) Service users have the specialist equipment they require to maximise their independence. Service users have the specialist equipment they require to maximise their independence. (OP NMS 22) The home is clean and hygienic. The home is clean, pleasant and hygienic. (OP NMS 26) The Commission considers Standards 24 and 30 (Adults 18-65) and Standards 19 and 26 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 Quality in this outcome area is adequate . This judgement has been made using available evidence including a visit to this service. The premises are fit for the purpose but need some refurbishment to maintain the standards required. EVIDENCE: A tour of the premises found them of a reasonable standard with some redecoration having taken place and some other improvements since the last Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 19 inspection so that standards are maintained. Some wear and tear was found on one unit, particularly with one set of furniture, although this was the exception to a generally well maintained home. One resident was concerned about damage to a wall in his living room which was causing him anxiety because it had not been repaired. Bedrooms seen did not contain comfortable chairs or a lockable facility which was commented on by one relative spoken to who said her relative would particularly welcome the chair so that her bedroom could be used more. Families were generally pleased with the standard of accommodation although one relative, although generally complimentary, thought that there was a lack of private space. A tour of the premises found it clean and hygienic with no offensive odour in place. One washing machine was not working as was one tumble dryer but the rest were functioning so that laundry could be dealt with appropriately. One resident is incontinent of urine but this was not noticeable during the inspection. Residents as well as staff contribute to the cleaning of the home as there are no specialist domestic staff and this seems to be satisfactory. The registration certificate was not displayed and could not be found which is contrary to the regulations for a registered home. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 (Adults 18-65) and Standards 27 – 30 & 36 (Older People) are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users are supported by competent and qualified staff. Service users are in safe hands at all times. (OP NMS 28) Service users are supported by an effective staff team. Service users needs are met by the numbers and skill mix of staff. (OP NMS 27) Service users are supported and protected by the home’s recruitment policy and practices. Service users are supported and protected by the home’s recruitment policy and practices. (OP NMS 29) Service users’ individual and joint needs are met by appropriately trained staff. Staff are trained and competent to do their jobs. (OP NMS 30) Service users benefit from well supported and supervised staff. Staff are appropriately supervised. (OP NMS 36) The Commission considers Standards 32, 34 and 35 (Adults 18-65) and Standards 27, 28, 29 and 30 (Older People) the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Staff appear to be recruited and trained to a good standard although documentary evidence for this needs to be present in the home so that the person in charge can access this when required. EVIDENCE: The standard in relation to recruitment could not be fully assessed as the documents relating to this were locked away in the registered manager’s absence. An interview with a newly appointed member of staff confirmed that she had been recruited in accordance with good procedures, including police checks, references and interviews. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 21 An examination of individual staff training files showed that staff are being trained regularly although they are not necessarily receiving the five days training per calendar year required. There was difficulty in fully assessing the training standard as most of the individual training folders were not in the home and the overall training record was only partially completed and did not show a full record of the history of training for each member of staff. Interviews with staff found them feeling well trained in their work so that they were confident in undertaking their role. A new member of staff felt she had received a good induction programme and confirmed that training has been arranged once her probationary period is completed. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 (Adults 18-65) and Standards 31-34, 37 & 38 (Older People) are: 37. Service users benefit from a well run home. 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. (OP NMS 31) Service users benefit from the ethos, leadership and management approach of the home. Service users benefit from the ethos, leadership and management approach of the home. (OP NMS 32) Service users are confident their views underpin all self-monitoring, review and development by the home. The home is run in the best interests of service users. (OP NMS 33) 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 homes record keeping, policies and procedures. (OP NMS 37) Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. Service users rights and best interests are safeguarded by the homes record keeping policies and procedures. (OP NMS 37) The health, safety and welfare of service users are promoted and protected. The health, safety and welfare of service users and staff are promoted and protected. (OP NMS 38) Service users benefit from competent and accountable management of the service. Service users are safeguarded by the accounting and financial procedures of the home. (OP NMS 34) 38. 39. 40. 41. 42. 43. The Commission considers Standards 37, 39 and 42 (Adults 18-65) and Standards 31, 33, 35 and 38 (Older People) 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home seeks residents’ views so that it can keep its service under review. It provides care in a safe environment for the protection of residents and staff alike. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 23 EVIDENCE: The home has a quality assurance policy and quality assurance team to consider these matters so that this remains high on the agenda. They last did an audit on 13th June 2006 and documentary evidence seen also shows that there was a meeting with residents held on 7th February 2006 as part of this process so that recent information in this area was available. The home has a file outlining the philosophy and methods to be used in assessing quality in the home which is a commendable practice. Monthly reports from managers visiting the home could not be found during the inspection and this was confirmed by documents held by the Commission which shows a shortage of such reports being forwarded as required. Interviews with residents and families showed that the home does actively seek the opinions of the former and will act upon them which is the basis of a quality assurance system. The home has full health and safety policies to underpin its practice and provides training to staff in health and safety issues as evidenced by some of the training documents seen. There has been a risk assessment of the premises in January 2006 and a general health and safety report in June 2006. The fire book was correctly completed which is a further indication of proper practice in the field of health and safety. An interview with a member of staff responsible for health and safety matters confirmed that he had been well trained in this subject and that he conducts appropriate checks of appliances and facilities which was confirmed by the documents seen during the inspection. Cambridge Road DS0000005259.V302245.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. Where there is no score against a standard it has not been looked at during this inspection. 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 2 23 X ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 2 STAFFING Standard No Score 31 X 32 X 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT Standard No Score 37 X 38 X 39 3 40 X 41 X 42 3 43 X 2 3 X 3 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 Cambridge Road Score 3 3 3 X DS0000005259.V302245.R01.S.doc Version 5.2 Page 25 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 YA6 Regulation 15 Requirement The registered manager to ensure that care plans are up to date, reviewed and simplified. (Previous timescale of 13th April 2006 not met). The registered manager to ensure that outstanding repairs are completed and that a comfortable chair is contained in each bedroom. The registered manager to ensure that all staffing files are available at all times and contain the required information. (Previous timescale of 13th April 2006 not met). The registered manager to ensure that there is a record of food consumed by residents. The registered provider to ensure that the Complaints’ Procedure contains the name and address of the Commission. DS0000005259.V302245.R01.S.doc Timescale for action 01/12/06 2. YA24 23 01/12/06 3. YA34 19 01/10/06 4. 5. YA17 YA22 16 22 01/10/06 01/01/07 Cambridge Road Version 5.2 Page 26 6. YA35 18 7. YA39 26 8 YA24 23 The registered manager to ensure that staff receive five days training a year, that this is fully documented in the training records and that these records are kept in the home. The registered provider to ensure that monthly visits are made to the home and a copy of the report sent to the Commission. The registered manager to ensure that the certificate of registration is prominently displayed 01/01/07 01/11/06 01/11/06 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. 2. Refer to Standard YA9 YA26 Good Practice Recommendations The registered manager is recommended to simplify and compress the risk assessments for residents. The registered manager is recommended to consider the provision of an extra lockable facility in residents’ bedrooms. Cambridge Road DS0000005259.V302245.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI. Cambridge Road DS0000005259.V302245.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. 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