Inspection on 08/03/06 for Church Road (41)

This inspection was carried out on 8th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church Road (41) 08/02/07

Church Road (41) 20/07/05

Church Road (41) 01/02/05

Church Road (41) 13/07/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Church Road (41) 41 Church Road Bebington Wirral CH63 3DY Lead Inspector Beate Roth Announced Inspection 8th March 2006 5:30 Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 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 Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 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. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Church Road (41) Address 41 Church Road Bebington Wirral CH63 3DY 0151 644 9493 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) Wirral Autistic Society Jane Anne Roberts Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The Manager is to complete her NVQ Level 4 in Management. The Manger to be registered for 134A Allport Rd for 3 months until an application to relinquish the registration of the home has been processed. 20th July 2005 Date of last inspection Brief Description of the Service: 41 Church Road is registered to provide personal care for three adults with a learning disability. The home is a two storey terraced property located in a residential area. On the ground floor there are 2 lounges, a kitchen with a dining area and a toilet/cloakroom. On the first floor there are three single bedrooms, an office/staff sleep in room, a bathroom and a separate toilet. There is a patio and a garden to the rear of the home. Parking is available on the main road. 41 Church Road is close to local shops and to public transport services. The home is run by Wirral Autistic Society who have several care homes for adults with a learning disability in the area. Wirral Autistic Society provides a range of services and facilities, which are fully utilised by the service users, accommodated at 41 Church Road. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 2 hours. During the inspection time was spent in the office examining records and policies and procedures and talking to the manager. A tour of the home was undertaken. A member of staff was spoken with and was observed delivering care to the service users. Service users were spoken with. What the service does well: What has improved since the last inspection? What they could do better: A full assessment of the safety of the cellar is needed and action is to be taken to address any risks identified, in order to ensure that the safety of service Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 6 users and staff is promoted at all times. A monthly written report on the conduct of the care home is to be provided to CSCI. 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. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 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 Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 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): 2, 4 and 5 A full assessment would take place to ensure that a service user’s needs could be met. Service users would have the opportunity to make visits to the home to assess if it is suitable. EVIDENCE: There has been no new service users admitted to the home since the last inspection. New service users would be assessed by the manager for the home and by a representative from day services. The manager would visit a prospective service user where they are living. Information would be gathered from the service user, their carers, social worker and any other relevant agencies. An examination of an initial assessment pro forma at a previous inspection indicated that all the information recommended in this standard is available. An assessment would be made if a service user moved to the home from another home within the Society. This information would be recorded. New service users have the opportunity to visit the home to assess if the home is suitable for them before making a decision as to whether to move in. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 9 Since the last inspection the contracts/statement of terms and conditions between the home and the service users have been revised. Each service user has a contract/statement of terms and conditions. These documents are signed by the service user and by a representative of the service user where appropriate. The contracts/statement of terms and conditions now indicate the additional costs that are payable when service users go out with staff, as service users sometimes pay for refreshments for staff. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 8 Care planning reflects the assessed and changing needs of service users. Service users are consulted with and take part in life at the home. EVIDENCE: Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 11 A sample of service user plans were examined and contained detailed and clear information to enable staff to provide appropriate support around day-to-day living and personal goals. A review had taken place within the last 6 months. The documentation available from reviews indicated that the service user, their relatives, social worker and other relevant individuals are invited to contribute to reviews. A service user interviewed commented positively on the support they receive from staff. The service user plans indicated that service user’s rights to live as independently as possible, in accordance with their abilities, is promoted by the home. There is evidence that agreement is reached with the service user, family and the funding authority with regard to any restrictions placed on a service users day-to-day life. Reactive plans, which detail behaviour management strategies are also available. Communication dictionaries are available for each service user. Service users’ views are obtained through their individual key workers. Service users are able to make their views known about the day care services offered at a service user run advocacy group, which meets every week. Some of the policies and procedures have been made available in formats that make them more accessible to some service users. It is recommended that where possible, further policies and procedures, the service users guide and service user plans are made available in formats suitable for the people for whom the home is intended. Service users are encouraged to contribute towards the running of the household. Service users go shopping and help with meal preparation in accordance with their abilities. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 15, 16 and 17 Service users are able to take part in appropriate activities that provide opportunities for their educational, social and personal development. The daily routines and arrangements for promoting relationships with family and friends, support service users. Varied and well-balanced meals are provided in homely surroundings. EVIDENCE: Service users attend day services where they are provided with a range of opportunities to promote their personal development. Service users have a timetable of activities, which has been drawn up to meet their needs, skills and individual preferences. Some of the opportunities available are horticulture, craftwork, community work experience, drama and physical education. Activities are provided by either Wirral Autistic Society’s day services or by outside organisations such as local colleges. Service users are provided with work experience opportunities in accordance with their abilities. Staff and records indicated that family links and friendships are promoted. The arrangements for contact with family are written into the service users’ care plans. Service users have the opportunity to meet people and make friends Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 13 with people who do not have their disability, through attendance at social clubs and through community activities. Discussions with the staff and observations confirmed that the home’s routines are flexible as much as possible and fit in with the needs and wishes of the service users. The records inspected indicate service users’ skills, preferred daily routines and the support service users need in their daily lives in order to make decisions and encourage independence. Care plans indicate the dietary requirements of service users. Advice is obtained from a dietician if this is required. A record is kept of food provided to service users. The records showed that well-balanced and varied meals are provided. A service user spoken with said that they help choose the meals and enjoy the meals provided. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 The health and personal care needs of service users are well met. Service users are protected by the home’s procedures and policies for the management of medication. EVIDENCE: Records detail the support service users need with their personal care. Observations indicated that staff, promote the privacy and dignity of service users. Consistency and continuity of support for service users is provided through the key worker system. Staff receive training on promoting privacy and dignity during their induction. Records of reviews indicated that service users have access to medical/health care professionals as needed. Service users are supported to attend health care appointments. Service users are supported and facilitated to take control of and manage their own healthcare in accordance with their abilities. A medication procedure is available which provides clear guidance. Medication is stored securely. The records of training indicated that staff have been trained in the safe handling and administration of medication. A selection of medication administration record sheets and corresponding medication were inspected and found to be in order. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 15 Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Staff training and policies and procedures are in place to ensure that service users views are heard and appropriate action taken. The practices at the home provide protection for service users form abuse. EVIDENCE: Staff reported that they elicit the views of service users in accordance with their abilities. Information is available to enable a complaint to be made by a service user or on their behalf, by an advocate. The complaint procedure includes the timescales for dealing with each stage of a complaint. The complaint procedure is displayed on the service users’ notice boards. The procedure is available in different formats to reflect the abilities of service users. A record is kept of any complaints made. The records indicated that a complaint had not been made since the last inspection. During this time no complaints have been made to CSCI. A copy of Wirral Borough Council’s adult protection procedure was available at the home. A shorter and more accessible version of the adult protection procedure has been made available by Wirral Borough Council and was at the home for staff to refer to. Staff have received training in the adult protection procedures. From discussion with a member of staff and from an examination of the financial records, the home’s policies and practices with regards to service users’ money and financial affairs safeguard service users. Monies held on behalf of service users are checked daily by staff, audited by the manager on a monthly basis and by the representative of the registered provider at their monthly visits. Receipts are maintained and records are signed by staff. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 17 Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 18 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 The home provides a comfortable and pleasant environment for service users. Safe working practices are in general promoted. EVIDENCE: The premises provide a comfortable environment for service users and are generally well maintained. The grouting around the shower is discoloured and would benefit from some attention. Safe working practices are in general promoted. A risk assessment is available for the risks presented by radiators that are not temperature controlled. Thermostatic mixing valves with lockable temperature controls are fitted to the bath and bathroom sink. A risk assessment has been carried out on the hot water outlets that do not have the temperature of the water regulated so it does not exceed 43 degrees centigrade. It continues to be recommended that design solutions that control the risk from all radiators and water that can exceed 43 degrees centigrade be provided. Window restrictors are provided in accordance with a risk assessment. A risk assessment of the security arrangements provided by the doors at the home is in place. At this inspection the cellar is being used as a gym for one service user. There is a risk assessment in place regarding this. This indicates that the service Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 19 user does not access this area unless accompanied by staff. A member of staff reported that they come to the home when not working to assist the service user in their personal training. The cellar presents hazards to the safety of service users and staff. There are exposed wires and nails protruding from exposed wooded beams. A full assessment of the safety of the cellar is to take place and action is to be taken to address any risks identified so as to ensure the safety of service users and staff at all times. This was discussed with the manager following the inspection. The home was clean, odour free and the standard of housekeeping on the day of inspection was high. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33, 34, 35 and 36 The wellbeing of service users’ is promoted by the home’s recruitment practices, the number of staff available and the training and support they have received. EVIDENCE: An examination of the rota indicates that the home is providing sufficient staffing levels. There is one member of staff on duty at all times. There is a network of support provided by Wirral Autistic Society for lone workers. Lone worker risk assessments are available. There are currently three permanent staff working at the home with absences being covered by permanent or bank staff. Bank staff have been recruited to work for Wirral Autistic Society to cover absences in the homes if needed or to provide support within the day care service. A comprehensive induction and foundation training programme is provided to staff. The induction and foundation training programmes have been developed in accordance with the National Training Organisation training targets. This training is also provided to bank staff so as to ensure that they are appropriately trained should they need to be deployed. Training needs are identified through supervision and appraisals. Supervision is provided to staff every 3 months. The National Minimum Standards recommend that supervision be provided on a two monthly basis. A thorough Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 21 agenda is worked through at each supervision session. A member of staff reported that they find supervision helpful and informative. This member of staff also reported that the manager is always accessible and is approachable. The understanding of staff of any training received is assessed during supervision. Training is provided to staff around equal opportunities. No new staff have been employed at the home since the last inspection. The recruitment records relating to bank staff were seen and contained the required information. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 and 39 The management systems in general, promote the wellbeing of service users. EVIDENCE: The manager of the home has had several years experience of management in a care setting. The manager has a Diploma in Social Work and has completed an NVQ Level 4 in management. The manager has undertaken periodic training to maintain and update her knowledge skills and competence. The manager is responsible for three other small homes that are owned by Wirral Autistic Society. A member of staff interviewed reported that they consider their views regarding the running of the home are sought and listened to. A clear complaint procedure is available. Staff meetings are held every month. There are a range of quality assurance systems in place. Wirral Autistic Society is accredited by the National Autistic Society which carries out an inspection of services provided. Wirral Autistic Society conducts an internal audit of the society as a whole on an annual basis. The views of service users Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 23 are obtained by key workers and the manager. The day service also provides a forum for service users to give their views on the services provided there. The views of GP’s are obtained regarding the provision of health care at the Wirral Autistic Society’s homes. Visits to the home by the representative of the registered provider are made. A sample of these reports were seen. Some did not contain a great deal of information on the suitability of the home environment, records and views of staff and service users. This would not enable an opinon to be formed as to how the home is operating. A copy of the Regulation 26 visit reports are to be forwarded to CSCI. Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 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 3 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 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 X 33 3 34 3 35 3 36 3 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 X 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 3 2 X X X X Church Road (41) DS0000018975.V283378.R01.S.doc Version 5.1 Page 25 No 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 YA24 Regulation 13 Timescale for action The registered person must carry 08/03/06 out a full assessment of the safety of the cellar and take action to address any risks identified in order to ensure that the safety of service users and staff is promoted at all times. The registered provider must 08/03/06 ensure that a monthly written report on the conduct of the care home is provided to CSCI. Requirement 2 YA39 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 YA8 Good Practice Recommendations It is recommended that where possible, further policies and procedures and the service users guide be made available in formats that are more suitable for the people for whom the home is intended. It is recommended that design solutions that control the risk from radiators and water that can exceed 43 degrees centigrade be provided. The grouting around the shower is discoloured and would DS0000018975.V283378.R01.S.doc Version 5.1 Page 26 2 3 YA24 YA24 Church Road (41) 4 YA36 benefit from some attention. Staff are to be provided with supervision at least 6 times per year. 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