Inspection on 02/02/06 for Elm Road, 13

This inspection was carried out on 2nd February 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Elm Road, 13 14/09/06

Elm Road, 13 16/08/05

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 Elm Road, 13 13 Elm Road Seaforth Liverpool Merseyside L21 1BJ Lead Inspector Mrs Janet Marshall Unannounced Inspection 02 February 2006 09:30 nd Elm Road, 13 DS0000005242.V281290.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 Elm Road, 13 DS0000005242.V281290.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. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Elm Road, 13 Address 13 Elm Road Seaforth Liverpool Merseyside L21 1BJ 0151 476 1967 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) Expect Limited Mrs Maria McCarthy Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 3 MD. Date of last inspection 16th August 2005 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 two 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, formerly 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. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the second of two inspection visits that are required at the home each year. The inspection was unannounced and took place over 3 hours. The inspection was conducted with the manager who was on duty at the time of the visit. Two residents were at home throughout the inspection. The requirements raised as part of the last inspection report were discussed and checked with the manager. The services responses to those are described within this report. A partial tour of the home was conducted. Care records and other required records were inspected. Records that were examined included a selection of residents care plans, daily diaries, medical notes, medication and records, staff rotas and certificates of health and safety checks. 2 residents and the manager were spoken with and their views obtained. It was not possible to obtain the direct views of one resident due to the nature of her disability however, her experiences were obtained through discussion with the manager, general observations and compliance with standards. What the service does well: In the main the house is comfortable and clean providing a safe and homely environment for residents. Care plans and other records about residents are generally well written and maintained ensuring that staff have the information they need to provide residents with the correct level of care and support. Residents are given opportunities to live fulfilling lives in accordance to their wishes. The service is good at ensuring that residents are assisted to make choices and decisions about their lives. Staff show that they respect residents by providing personal support in a sensitive and flexible way. Residents are supported by staff that are qualified and competent to do their jobs. The service ensures the protection of residents by following a robust recruitment procedure. Parts of the home have been decorated and refurbished since the last inspection records & discussions showed that residents were involved in selecting colour schemes. Residents benefit from a service, which is well managed. The service carries out processes, which take account of the views of the residents and their representatives. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Elm Road, 13 DS0000005242.V281290.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 Elm Road, 13 DS0000005242.V281290.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): None of these standards were assessed during this inspection. Key standard 2 was assessed at the last inspection and was met. EVIDENCE: Key standard 2 was assessed and met at the last inspection. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 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 the following standard(s): 7. Key standards 6 & 9 were assessed at the last inspection and were met. Residents care plans reflect they are encouraged to make decisions with the assistance that they need. EVIDENCE: The manager said residents are supported and encouraged to take part in aspects of live in the home in accordance to their ability and understanding. Details of their ability and support required were recorded in their plans of care. Through discussion and observation the manager showed that she respects resident’s rights to make decisions. Choices and decisions made for residents by others and why are agreed in their plans of care. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 10 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): 11, 13 & 16 Key standards 12, 15 & 17 were assessed at the last inspection and were met Residents are given opportunities to live fulfilling lives in accordance to their wishes. EVIDENCE: A requirement was raised as part of the last inspection report for records to be kept up to date to show that residents are given opportunities for personal development. Both residents who have mental health problems choose not to go outside the home. The manager and staff respect their decision and recognise that because of this it is particularly important that they are given opportunities for stimulation at home. Records that were examined are now well kept and supported this. Details of activities, interests and hobbies that residents are offered and take part in at home were recorded in good detail. One resident enjoys spending time in her room listening to her radio, watching television in the company of others in the main lounge and reading. Another resident enjoys pampering sessions, which include having her nails manicured, and her hair washed and styled. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 11 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 & 21 Key standards 19 & 20 were assessed at the last inspection and were met. Residents receive personal support according to their wishes. EVIDENCE: Both residents require some physical support with personal care but require mostly advice, guidance & support. Both care plans had a detailed and agreed routine, which showed a great deal of staff input & guidance and the importance of the routine for the residents. Regular care plan reviews allow staff to address any issues or changes to care that may be necessary. These records were seen and were detailed and satisfactory. A resident has passed away since the last inspection. Her death was expected following a short illness. The resident was cared for and died in surroundings with those around her as chosen by her and her family. Her funeral was arranged and took place in accordance to her and her families wishes. These were recorded in her care file. The manager showed that she dealt with the situation sensitively and with respect supporting the other residents to deal with their friends death. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 12 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): None of these standards were fully assessed during this inspection. Key standards 22 & 23 were assessed at the last inspection and were met EVIDENCE: There have been no complaints made about the service in the last twelve months. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 13 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, 25, 26, 28. Key standards 24 & 30 were assessed at the last inspection. Standard 30 was met. Standard 24 was not fully met so was reassessed during this inspection. Most parts of the home were clean tidy and maintained to a good standard providing a safe and comfortable environment for residents, however this is compromised by some minor wear and tear. EVIDENCE: A requirement was raised as part of the last inspection report for the kitchen walls and woodwork to be painted. This was because they were heavily stained making the room look dark and dull. A tour of the kitchen showed that the areas have been painted since the last inspection. One resident said that she helped to choose the colour and thinks that the kitchen looks much brighter since being painted. A tour of the kitchen showed that the kitchen units are in a poor state of repair, which compromises the comfort and dignity of residents and lets down the overall appearance of the home. This has been raised as a recommendation as part of this inspection report. All communal areas of the home were seen on the day of the inspection in addition to the outside front & rear of the property. All areas were clean and tidy and maintained to a good standard. Both residents bedrooms were Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 14 viewed, they were comfortable & personalised to a high standard meeting the needs and lifestyles of individual residents. A requirement was raised as part of the last inspection report for fire doors to be made safe. This was because some fire doors were hazardous as when shut did not fit tightly into the door recess. Examination of fire doors showed that they were all safe. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 15 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): 32 & 34. Key standard 35 was assessed at the last inspection and was met. Residents are supported by qualified and competent staff. The homes recruitment procedures ensure the protection of residents. EVIDENCE: A selection of staff files were examined. These all contained the required identification evidence, reference copies, Criminal Record Bureau (CRB) checks and proof of qualifications. The recruitment policy is robust and meets the minimum standards. Staff files that were examined showed evidence that staff have undertaken periodic training which is required by regulation and to enable them to meet the needs of the resident group. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 16 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 & 39 Key standard 42 was assessed at the last inspection and was met. The home is run to a high standard which benefits the residents. Systems are in place to seek the views of residents. EVIDENCE: Administration and recording systems in the home are of a high standard, being detailed, relevant and up to date. Residents opinion is valued by staff through the day-to-day running of the home. Observation on the day of the inspection also supported this. The manager and staff are always observed to be respectful towards residents placing them at the centre of their work. The staff team is consistent and staff meeting minutes seen reflected that the manager & the staff are dedicated to residents’ welfare and to providing a high quality service. Records showed that quality monitoring systems are in place at the home. This involves residents and/or their relatives/representatives being consulted on their views about the home. This is done through discussion, which is recorded and/or written questionnaires. This is an important process as it Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 17 shows that the home is run in the best interests of the residents. Also as part of a quality assurance process and in accordance with Regulation 26 of the Care Homes Regulations 2001 Amended (2004), a representative for the home visits the premises monthly. They interview residents and staff and inspect the environment. It is important that this is done to check records and form an opinion of the standard of care in the home. Following the visit the representative writes a report and sends a copy to the Commission. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 18 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 X 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 X ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 X 28 3 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X 3 X X X LIFESTYLES Standard No Score 11 3 12 X 13 3 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 X X 3 3 X 3 X X X X Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 19 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. Standard Regulation Requirement Timescale for action 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 YA24 Good Practice Recommendations Kitchen units should be repaired or replaced. Elm Road, 13 DS0000005242.V281290.R01.S.doc Version 5.1 Page 20 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. 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