Inspection on 22/11/05 for Cumberland Gate, 44

This inspection was carried out on 22nd November 2005.

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

Other inspections for this house

Cumberland Gate, 44 08/01/07

Cumberland Gate, 44 12/05/05

Cumberland Gate, 44 04/03/05

Cumberland Gate, 44 17/11/04

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 Cumberland Gate, 44 44 Cumberland Gate Netherton Liverpool Merseyside L30 7PZ Lead Inspector Debbie Corcoran Unannounced Inspection 1:45 22 November 2005 nd Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Cumberland Gate, 44 Address 44 Cumberland Gate Netherton Liverpool Merseyside L30 7PZ 0151 531 6039 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) Autism Initiatives Ms Susan Ann Windsor Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 3 LD. The service should, employ a suitably qualified and experienced Manager who is registered with the CSCI. Date of last inspection Brief Description of the Service: 44 Cumberland Gate is a small home registered for three people who have a learning disability. The service is provided by Autism Initiatives. Autism Initiatives was formerly called the Liverpool and Lancashire Autistic Society and it was established in 1971. It is in the voluntary sector and has charitable status. Autism Initiatives provide a range of services to adults and children who have autism. These services include residential care, day care, supported tenancies, outreach, domiciliary care, respite and educational services. 44 Cumberland Gate is a four bedroom property located on a residential housing estate in Thornton, Merseyside. The house is a domestic property which promotes the principles of ordinary community living. The service users are supported by a small well established staff team. There are two staff on duty to support the service users throughout the day and a sleep in member of staff. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The Inspection was unannounced and took place over 3.5 hours. During the visit two of the three service users were spoken with and two members of the staff were spoken with. A tour of the home was carried out. Service user plans, staff files, health and safety records and other relevant records were examined in some detail. What the service does well: What has improved since the last inspection? What they could do better: The home does not have a manager who is registered with the commission. However, it must be acknowledged that the current manager is making such an application. A number of requirements and recommendations are outstanding from previous inspections. These include the development of a service users guide, service user contracts and staff to be trained in the administration of medication. The manager should review the appropriateness of one of the service user’s bedrooms in terms of size. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 6 The registered person should review the allocated budget for food for the home. There are a number of staff vacancies and this is impacting on staff and service users. Staff recruitment and selection procedures need to be more effective in ensuring staff vacancies are filled within a shorter timescale. 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. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 5 The home has a statement of purpose but the service user guide is still in the development stage. The service users do not benefit from having a statement as to the terms and conditions of their occupancy as they do not have a form of contract with the home. EVIDENCE: The home has a statement of purpose which includes the use of photographs so that service users and relevant others can see what the home looks like. A service user guide is being developed but is not yet complete. The home has been given numerous requirements to produce a service user guide and continues to fail to meet this standard. The guide should be produced to provide current and prospective service users with information on the home and it should be produced in accessible formats. Service users have not been provided with a contract / statement of terms and conditions. A contract should be developed and provided to service users which sets out the services and facilities offered by the home, terms and conditions of occupancy, fees, rights and responsibilities of parties and other issues as outlined in the national minimum standards. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 9 Standard 2 above is a key standard which should be assessed during the course of an inspection year. However, there have been no new service users to the home for a number of years and therefore this standard could not be practically assessed. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 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, 9 Service users have a plan of care which clearly reflects their needs and the plans are reviewed and updated regularly. When service users are involved in an activity which involves taking risks the risk is assessed and managed in order for service users to maintain and develop their independent living skills. EVIDENCE: Each of the service users has a care plan / support plan. The plans include information on how to meet the person’s physical, social and emotional needs. The plans focus on the support the service user needs as a result of living with autism and provide the staff team with information on the service users needs, goals and routines. Each of the service users has a review of their support every six months. These reviews usually involve a meeting which includes the service user, members of their family or other representatives, social worker and relevant others. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 11 When a service user is involved in any activities which are thought to present a risk then a risk assessment is carried out. The risk assessments include a good level of information on what the potential risks are to the service user and the steps which staff need to take to minimise the risk or prevent the risk from occurring. The risk assessments cover many different aspects of the service user’s support. For example support with keeping safe, using public transport, dealing with socially difficult situations. Some of the risk assessments need to be reviewed. The manager reported that the service users are encouraged to communicate their needs and choices through the use of pictures. This is a valuable means of communication and is enabling the service users to make everyday choices. Through discussions with service users, staff and care planning it is evident that service users are involved in the practical day to day running of the home with regard to household tasks for example shopping, cooking and cleaning. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 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): 15, 16, 17 Service users are supported to maintain relationships and their responsibilities and choices are well recorded. Service users have choice in meals, however that choice is restricted as to what is available, which at the time of inspection was not great. EVIDENCE: Service users are reported to be encouraged to develop and maintain relationships through work placements, college, social groups and in using community facilities. Service users and staff maintain regular contact with members of the service user’s family. Each of the service user’s has a support plan and alongside this there are many written guidelines for supporting the service users with particular tasks or describing their preferences or choices. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 13 The service users are encouraged to communicate their needs and choices through the use of pictures. This is a valuable means of communication and is enabling the service user to make everyday choices. Through discussions with service users, staff and care planning it is evident that service users are involved in the practical day to day running of the home with regard to household tasks. The food contents in the kitchen was examined. It was found that there was not a great amount or variety of food stored. This was discussed with the manager who reported the food budget to be approximately £90 per week. This needs to be reviewed as a matter of priority by the registered person. The service user’s are reported to choose their food on a daily basis and this is then recorded. Pictures of food are used to aid choice and plan shopping. There are occasions when the kitchen is locked and this clearly which restricts the service user’s access to food. This restriction is based on a risk assessment in relation to one of the service users. Staff must ensure that locking the kitchen is used minimally so as to cause least restriction to all of the service users whilst also protecting one of the service users from potential harm. Not all food was stored appropriately as food which has been opened must be date labelled. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 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, 20 Service users are supported by staff who know their personal care needs and preferences well. Information on the service user’s needs with personal support is clearly recorded. Service users are supported with their physical and emotional needs. Medication is handled safely and in accordance with policies and procedures. EVIDENCE: Some members of the staff team have supported the service users for a considerable length of time and therefore have a good understanding of their personal support needs. Service user plans include written guidelines as to how to support the service users with personal support. Staff are aware of these guidelines are therefore clear as to what each of the service users needs and routines are and the service users benefit from consistency in how they are supported. Each of the service users has a separate file / record relating to their health care needs. These records showed that service users are being supported to attend a variety of health appointments. Records showed that service users weight is regularly checked and monitored. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 15 Medication records and the storage of medication were examined. The home maintains a record of all medication received, administered and stock checked. There were some gaps in the medication administration records, this was reported to be because agency staff had not completed the records appropriately. All staff must be clearly aware of their duties to record the administration of medication accurately. Information is also maintained on what particular medications are taken for and the possible side effects of these medications. Health and medication reviews form part of the general review process which service users have every six months. The home has a policy on medication and medication guidelines. Two members of the staff team have received training in the administration of medication. This should be extended to all members of the staff team. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 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, 23 The home has an appropriate complaints procedure. Policies, procedures and practices are in place which aim to protect service users against abuse or neglect. However the lack of a policy and procedure on service user’s payment of travel expenses to staff leaves service users and staff in a potentially vulnerable position. EVIDENCE: The home has a complaints procedure which is time scaled appropriately. The procedure includes details of the Commission for Social Care Inspection. A leaflet explaining the complaints procedure is also available and this includes pictures to aid understanding and one of the service users has been provided with an accessible guide for making a complaint. There have been no complaints made to the home since the previous inspection. The home has an adult protection policy and procedure and a whistle blowing policy. Staff records show that all staff have received training in adult protection. Where appropriate there is information in service user files on responding to challenging behaviour and guidelines which are specific to the needs of the individual. Staff training records show that staff have received training in responding to challenging behaviour. In order to safeguard service users the home has a policy and procedure on the management of service user’s money, valuables and financial affairs. However, at a previous inspection it was identified that staff are paid directly by service users if the service user travels in the car of a member of staff. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 17 There is no policy and procedure on service users money being paid to the organisation / staff for travel purposes and this therefore leaves both service users and staff in a vulnerable position. A requirement was given for this to be addressed but the issue remains outstanding. A representative from Autism Initiatives carries out financial audits at the home. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 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): 25 One of the service user’s bedrooms is small and may not be appropriate for the person’s needs. EVIDENCE: The home was originally a three bedroom house. One of the bedrooms has been partitioned in order to create a fourth bedroom which is used as an office / staff sleep in room. The service user’s room in question is less than 10sqm. As the room is the same size as on 31.03.2002 it does in fact meet the national minimum standard for an existing care home. However, the manager should review the appropriateness of the service user’s bedroom and consult with the service user and their representatives as part of this review. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 19 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 The home is running with a number of staff vacancies and staff absence and therefore the use of agency staff can be higher than would be expected and staffing levels have been reduced to one on recent occasions. This restricts the service users choice and autonomy. Staff recruitment and selection procedures are good in that they aim to promote the safety and well being of service users. However, the current arrangements are not appropriate in ensuring that vacant hours are recruited to in a timely way and in line with the needs of the service users. EVIDENCE: The findings at the last inspection were positive in relation to the stability of the staff team, there being a full compliment of staff and staff recruitment and selection procedures being effective. Since that time a number of staff have left the home and the staff team is running short of hours in excess of 40 per week. Staff leave and sickness is adding to this shortage and at the time of the inspection the home was running on a reduced staff team and this was causing difficulties in terms of the use of agency staff or occasions were one member of staff has worked on their own supporting the three service users. A recent example of this was on a Saturday when the three service users would have had no opportunity for any community access. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 20 Staff recruitment and selection is a central responsibility which is controlled at head office. Staff recruitment and selection policies and procedures are in place. Examination of staff files showed that two written references are obtained for new employees and a criminal records disclosures is obtained prior to the commencement of their employment. The fact that there are a number of staff vacancies at the home indicates that there are some difficulties with staff recruitment and selection. The manager currently has minimal involvement in staff recruitment. Staff recruitment needs to be more effective than at present and allowing the manager some degree of autonomy in the process might alleviate some of the difficulties with recruitment. Service users are reported to be involved in staff recruitment and selection across the organisation but there was no evidence that this has included the people living at 44 Cumberland Gate. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 39, 42 Practices which promote the health and safety of service users and staff are in place. The service users have not benefited from regular unannounced visits to the home carried out by a representative from Autism Initiatives. EVIDENCE: The home has a new manager in post. This person is making an application for registration with the commission. A number of policies and procedures are in place which aim to ensure the health and safety of service users and staff and these include policies on health and safety, infection control, fire safety and moving and handling. Fire safety and health and safety practices are adopted. Records of fire and health and safety checks were checked and found to be up to date. Water temperatures are regulated. The temperature of the water was tested in the bathroom and was close to 43 c thus ensuring the service users are not at risk from scalding. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 22 The registered person should ensure that the home is visited on an unannounced basis at least once per month and provide a report on the findings of the visit to the Commission in line with Regulation 26 of the Care Home Regulations 2001. These visits should form part of the quality assurance process and should involve seeking the views of service users (and their representatives as appropriate) and staff in order to form an opinion on the standard of care provided. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 x x x 2 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 x 3 x Standard No 24 25 26 27 28 29 30 STAFFING Score x 3 x x x x x LIFESTYLES Standard No Score 11 x 12 x 13 x 14 x 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score x x 2 3 x x CONDUCT AND MANAGEMENT OF THE HOME 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Cumberland Gate, 44 Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score x x 2 x x 3 x DS0000005238.V272262.R01.S.doc Version 5.0 Page 24 Are there any outstanding requirements from the last inspection? Yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA1 YA5 Regulation 5 Requirement Timescale for action 21/02/06 21/02/06 3. YA23 4. 5 6 7 YA20 YA20 YA33 YA33 8 YA17 A service user guide must be produced 5(c) A standard form of contract for the provision of services and facilities by the home to service users must be produced. 13(6) There must be a clear policy and procedure on service users money being paid to the organisation / staff for travel purposes. 18 (c ) (1) Staff who are responsible for the administration of medication must be appropriately trained. 13 (2) Medication administration records must be maintained accurately at all times. 18 (1) (a) The registered person must (b) ensure that vacant posts are appointed to. 18 (1) (a) The registered person must review the staff recruitment and selection process and implement strategies to ensure this is more effective 16 (2) (i) The registered person must review the budget arrangements for food / provisions and provide the commission with information on the outcome of this review. DS0000005238.V272262.R01.S.doc 21/02/06 21/03/06 21/12/05 21/01/06 21/01/06 21/01/06 Cumberland Gate, 44 Version 5.0 Page 25 9 10 YA17 YA39 13 (3) 26 (5) Food must be stored appropriately and safely at all times. The registered person shall ensure that the home is visited at least once per month on an unannounced basis and shall supply a copy of the report following the visit to the Commission. 21/12/05 21/12/05 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 YA25 Good Practice Recommendations The manager should review one of the service user’s bedrooms with the service user concerned and their representatives / advocates. Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 26 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 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 Cumberland Gate, 44 DS0000005238.V272262.R01.S.doc Version 5.0 Page 27 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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