Inspection on 16/08/05 for Elm Road, 13

This inspection was carried out on 16th August 2005.

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

Other inspections for this house

Elm Road, 13 14/09/06

Elm Road, 13 02/02/06

Elm Road, 13 09/11/04

Elm Road, 13 03/06/04

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

CARE HOME ADULTS 18-65 13 Elm Road 13 Elm Road Seaforth Liverpool L21 1BJ Lead Inspector Janet Marshall Unannounced 16 August 2005 th 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 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 Stationary 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. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 13 Elm Road Address 13 Elm Road Seaforth Liverpool L21 1BJ 0151 476 1967 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Expect Ltd Mrs Maria McCarthy PC - Care Home Only 3 Category(ies) of MD - Mental Disorder - 3 registration, with number of places 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 3 MD. Date of last inspection 9th November 2004 Brief Description of the Service: 13 Elm Road is a mid-terraced house situated in a residential area of Seaforth. Parking is available on the road at the front of the house. The home is registered to provide care and support for three adults who have mental health difficulties. Currently there are three women in residence.The home is generally well maintained. The home is of a domestic setting in all aspects and is indistinguishable as a care home. The home is operated by Expect, formely Sefton Support Services. Crosby Housing Association owns the house. Staff are on duty 24 hours a day to provide care and support for the service users who live there, the overall philosophy being to maximise ordinary living and to promote independence of the service users in all aspects of their daily life. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Two inspection visits are required at the home each year, this was the first. The inspection was unannounced and took place over four hours. The registered manager of the home was on annual leave. The requirements and recommendations from the last inspection report were discussed and checked with a member of staff. Some of these have been met, it was not possible to check all of them due to the manager not being on duty. That is because confidential information that needed to be checked can only be accessed by the manager and was correctly locked away. Other records were examined including residents care plans, daily diaries, medical notes, medication sheets, staff rotas and certificates of health and safety checks. Discussion took place with all residents. Two members of staff were on duty at intervals during the inspection discussion also took place with them. One resident was ‘case tracked’. Case tracking means that the inspector concentrates on the care given and experiences of one or more residents to ensure that the persons needs are recorded in their care plan and are being met. The resident was very helpful she talked about her care plan and confirmed the information included in it. A tour of the inside and outside of the home took place. What the service does well: What has improved since the last inspection? Arrangements following the death of a resident have been agreed and recorded in their individual plans which will ensure that the event is handled with respect and as the resident would wish. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 6 One residents bedroom has been re-decorated making it more attractive and comfortable for her. The lounge has been redecorated and refurbished making it pleasant and more comfortable for all residents. All staff that administer medication have received training. The hall stairs and landing are now cleaner and brighter since being painted 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. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 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 standard(s) 2 There was a good standard of assessments enabling the home to be sure of meeting residents care needs. EVIDENCE: There have been no new residents admitted to the home since the last inspection. Copies of assessments carried out prior to admission were seen in all residents care files. The assessment of the resident case tracked was looked at in detail. The resident case tracked spoke about what she is able to do for herself and what she needs help to do, these were the same as those written in her assessment. Staff spoken to knew a lot about the resident and her strengths and needs. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 9 & 10 The service provides care plans for the residents which are reviewed and updated regularly, ensuring that current and changing needs are met. Residents care plans reflect they are encouraged to take responsible risks in their lives, they are reviewed regularly ensuring that they are safe and effective. Information about residents was stored securely to ensure that their confidences are kept. EVIDENCE: A care plan was viewed for each of the residents. They were well written and included a good amount of information to enable staff to meet each persons needs. The care plans showed that they have been recently reviewed and updated, this ensures that resident’s needs are being met and any changing needs are recorded. The care plan of one resident who was ‘case tracked’ matched the information gathered during discussion with her. This resident said that she enjoys living in the home. The resident also said that the staff are very good because they look after her well and encourage her to do the things that she enjoys doing. Risk assessments were viewed for all residents, they showed that they have been reviewed and updated ensuring that residents continue to take responsible risks. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 10 Care plans and other information about residents were securely locked away in the office. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11, 12, 15 & 17 Records of activities that residents are involved in are not recorded as well as they should be to show that they are given opportunities for personal development. Relationships are encouraged so that residents maintain contact with family and friends. Residents are encouraged to eat food that is healthy and enjoyable. EVIDENCE: All residents choose not to take part in activities outside the home, however they described activities, interests and hobbies that they are involved in the home. One resident said that she particularly enjoys reading and watching TV. This information was recorded in her care plan. At the last inspection an up to date record of activities showed that residents were being offered a variety of activities to take part in at home, however these records have not been updated for several months. They need to been kept up to date to show that residents are given opportunities for personal development. Discussion and records also showed that residents are supported and encouraged to develop and maintain contact with family and friends. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 12 There was good stock of fresh, tinned and frozen foods kept at the home. The residents spoken with said that they choose food they eat. The residents described the food that they like and dislike, this information was also in their care plans. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19, 20 & 21 Resident’s health care is well recorded and monitored to ensure that their health care needs are met. Medication is administered and stored appropriately and records were well kept to ensure the protection of residents. Arrangements following the death of a resident were agreed and recorded in their plans ensuring that the event will be handled with respect and as the resident would wish. EVIDENCE: Records showed that the health care needs of residents are recorded in good detail. Records about resident’s healthcare were well kept and up to date. Support and understanding is given to residents who refuse to attend healthcare appointments and details of this and how it is managed are recorded in their care plans. Community nurses regularly visit the home to administer specialist treatment to residents details of the visits and medication administered was seen at the home. Medication at the home was in date and stored in a locked cabinet in the office. At the last inspection it was noted that some staff were administering medication without having the necessary training. At this inspection it was confirmed that all staff that administer medication have undertaken the required training. Records that were seen showed that medication is signed for when administered to residents. Items of 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 14 unused or unwanted medication are returned to the pharmacist a record of this was seen at the home. Since the last inspection arrangements following the death of residents have been agreed and recorded in their individual plans. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 15 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 standard(s) 22 & 23 There were no recorded complaints since the last inspection. A Resident was confident that her concerns or complaints would be listened to and acted upon. A clear complaints procedure was available so that residents can use it. Safeguards were in place to protect the people living in the home from abuse. EVIDENCE: Records showed that there have been no complaints made at the home since the last inspection. Residents spoken with said that they don’t have any concerns or complaints about the home or the staff. They said that if they did they would feel confident about telling somebody. Copies of the homes complaints procedure were available in the homes information pack and the staff handbook. A number of policies and procedures were in place to protect the safety, health and welfare of residents including a copy of Seftons Local Authority Protection of Vulnerable Adults Procedure (POVA), which clearly describes what action, must be taken in response to suspicion or evidence of abuse. Staff spoken with showed a good awareness of the different types of abuse and their responsibility to protect vulnerable adults. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 16 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 standard(s) 24, 30 Improvements have been made to the home making it more comfortable for residents. Policies and procedures were in place to ensure that a high standard of cleanliness and hygiene is maintained, however some of these are negated by the condition of the kitchen which puts the health of residents at risk. EVIDENCE: A full tour of the home was carried out. Most areas of the house were clean, tidy and well maintained. A lot of work has been carried out at the home since the last inspection making it more comfortable for residents. One residents bedroom has been redecorated to a high standard. The resident said that she was involved in choosing colour schemes and is happy with the improvements. The lounge has been redecorated and the carpet and curtains have been replaced, a new rug and pictures have been bought for the lounge. The hall stairs and landing has also been painted making it look cleaner and brighter. Residents spoken with said that they were involved in the improvements and are happy with them. The kitchen walls and woodwork are heavily stained making the room look dark and dull. Some kitchen cupboards have doors hanging off and others are in a poor state of repair, the kitchen needs to be painted and cupboards 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 17 repaired or replaced making it more hygienic and improving the area for residents. The staff handbook contained a number of policies and procedures relating to cleanliness and hygiene. A member of staff showed awareness of the importance of maintaining a clean and hygienic environment for the people who live there. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 18 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Staff have completed the required training, which enables them to meet the needs of residents. Staffing arrangements are reviewed regularly to ensure that they meet the needs of residents. EVIDENCE: The staff rota was examined and showed there is a minimum of one member of staff on duty during the day. On several days during the week this is increased to two at intervals during the day to meet the needs of residents. One sleep–in staff is on duty at night. The resident case tracked said staff were helpful and always made time to listen to or help her. She said, “I trust them and we have a laugh too”. Monthly reviews are recorded and were examined. These showed staff have very good skills in monitoring and addressing needs with residents, helping them to be positive about their lives and their achievements. Staff records were not available because the manager who is the only person that has a key locked them away, this is to protect staff confidentiality. A member of staff spoken with confirmed that she has completed most of the training that is required as well as training that is specific to the needs of the residents. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 19 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 38, 40 & 42 The manager of the home is positive, approachable and inclusive benefiting both residents and staff. The Commission are receiving monthly quality audit reports to ensure resident’s views about the home are important. Policies and procedures were in place to protect the health, safety and welfare of the residents and staff, however some of these are negated by hazards, which have the potential to put residents at risk. EVIDENCE: Staff said that the manager is very approachable and supportive of both residents and staff, the manager was also described by staff as being positive and inclusive. A member of staff said that they have completed health and safety training. Certificates were not available to support this because they were locked away with other staff details. A detailed health and safety manual was available at the home. The manual included certificates of safety checks and details of tests carried out on the environment. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 20 A number of fire doors located around the home did not shut tightly into the recess this is a fire hazard. The doors must be adjusted so that they shut properly. 13 Elm Road F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 21 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 x 3 x x x Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 x x 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 x x x x x 2 Standard No 11 12 13 14 15 16 17 2 3 x x 3 x 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 13 Elm Road Score x 3 3 3 Standard No 37 38 39 40 41 42 43 Score x 3 x 2 x 2 x F53 F03 13 Elm Rd S5242 V245854 16.08.05 Stage 4.doc Version 1.40 Page 22 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 YA11 Regulation 16(2)(n) Requirement The manager must ensure that records of activities are kept up to date to show that residents are given opportunities for personal development. The manager must make arrangements for the redecoration of the kitchen. The manager must ensure that Fire doors around the home are made safe. Timescale for action 31/10/05 2. YA24 23(2)(b) 31/11/05 3. YA42 12(1)(a) 31/10/05 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. 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