Inspection on 09/05/06 for Gladstone Road, 29

This inspection was carried out on 9th May 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 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 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Gladstone Road, 29 07/06/07

Gladstone Road, 29 02/02/06

Gladstone Road, 29 24/10/05

Gladstone Road, 29 14/12/04

Gladstone Road, 29 08/07/04

Gladstone Road, 29 01/03/04

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

CARE HOME ADULTS 18-65 Gladstone Road, 29 29 Gladstone Road Seaforth Liverpool Merseyside L21 1DG Lead Inspector Mrs Janet Marshall Unannounced Inspection 8th May 2006 09:00 Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Gladstone Road, 29 Address 29 Gladstone Road Seaforth Liverpool Merseyside L21 1DG 0151 949 0966 Telephone number Fax number Email address Provider Web address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) www.peterhouseschool.org Autism Initiatives Mr Simon Thomas Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 3 LD. Date of last inspection 2nd February 2006 Brief Description of the Service: 29 Gladstone Road is a mid-terraced house in a residential area of Seaforth. Parking is outside the property in the street. The home is managed by Autism Initiatives. The home is registered as a care home to provide care and support for 3 adults who have a learning disability. There are currently three men living at the home. The staff group appears committed in providing a high level of support. Relationships with neighbours are reported being good. The overall philosophy of care is to promote independence and to maximise ordinary living for all the residents. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection visit (site visit) at the home this inspection year. The inspection was unannounced and took place over one day for a total of 6 hours. The Commission considers 22 standards for Care Homes for Adults (18-65) as Key Standards, which have to be inspected at least once in a 12-month period. All Key standards, which are identified within the main body of the report, were inspected during this inspection. During the site visit the requirements and recommendations from the last inspection report were discussed and checked with the manager. Only one has been fully met. Those that have not been met have been raised again as part of this report in addition to a number of other statutory requirements and good practice recommendations identified during this inspection visit. 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. Two residents were “case tracked”. Case tracking means that the Inspector concentrates on the care given and experiences of one or more residents to get an idea of what is like to live at the home and how that person’s needs are being met. A pre - inspection questionnaire, which was sent out to the home was completed by the manager and returned prior to the inspection. The manager, 3 staff and 1 resident were interviewed during the site visit. Other residents were met with. A telephone interview took place with a residents relative several days after the site visit. Prior to the inspection visit Surveys from the Commission for Social Care and Inspection titled ‘Have your say about…’ were given out to all three residents none of them were returned. Information provided in the pre - inspection questionnaire, comments made during interviews, observations made and records examined during the visit have been used towards measuring standards for the purpose of this report. What the service does well: There was a warm and friendly atmosphere at the home. Discussions & observations showed that staff have a positive attitude towards the residents and their disabilities. The health care needs of residents are well met which ensures their physical wellbeing. The service provides a good level of training for permanent staff to ensure that they are competent and qualified to meet resident’s needs. Procedures and practices carried out in the home ensure that residents live in a comfortable, safe and clean environment. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 6 Resident’s relatives were positive about the care and support that is provided at the home. 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. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 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 Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 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&5 The quality in this outcome area is good. The judgement has been made using available evidence including a site visit. Procedures are in place, which ensure that prospective residents needs are assessed. Residents have contracts which show that they agreed with the terms and conditions of the home. EVIDENCE: There have been no new residents admitted to the home since the last inspection. Procedures were available at the home to show that new residents are admitted only on the basis of a full assessment undertaken by the home and other relevant professionals. None of the current residents care files included copies of initial assessments carried out prior to their admission to the home. The manager explained that this is due to the length of time that they have been living at the home. Records viewed at the home showed that existing residents needs are assessed as part of the homes reviewing procedures. Completed contracts for two residents were available in their personal files. The manager said that a contract for the other resident has been sent out to his representative who has not yet returned it. All residents’ contracts are agreed by their representatives because of their limitations. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 9 The manager explained that resident’s contracts have been reviewed and updated. Contracts included the following information: Contract statement, Residence – trial period, Permanent residence, Fees, Rooms, Personal items, Health – medication, Care/support, Health & safety, Visitors, summary of the complaints process, Registration and Declaration. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 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 The quality in this outcome area is adequate. The judgement has been made using available evidence including a site visit. Care plans are not being regularly reviewed therefore there is a risk that changing needs are not being identified and met. Procedures at the home limit the choice and control that residents have regarding their personal finances. EVIDENCE: A selection of care plans, review documents and daily records completed since the last inspection were examined. Care plans showed that they have not been reviewed and updated for sometime. This was raised as a requirement at the last inspection. New support plans described by the manager, which have been introduced, were viewed and have not yet been fully completed for any of the residents. A requirement was raised as part of the last inspection report for a full review of a residents needs to take place because it was felt that the home was not fully meeting the persons needs. The manager confirmed a review has not yet taken place but confirmed arrangements for this. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 11 Staff were observed offering choices to residents and responding respectfully to their wishes. Care plans provided information about the assistance residents need to enable them to make choices and decisions, because this information has not been reviewed and updated for sometime there is a risk that needs are not being fully met. Resident’s individual bankbooks were seen at the home. They showed that each resident has their own bankbook showing transactions made, and that the accounts are part of a single account managed by Autism Initiatives. Information was provided to show that the manager is working towards supporting residents to open their own bank accounts from their home address. The current system does not allow residents to access their money directly. Withdrawal request forms have to be completed and forwarded onto head office for authorisation by a senior manager who then withdraws money from the bank on behalf of the resident. There is a risk that residents are left short of money because this process can take several days. Risk assessments were in place for all residents, they showed that residents can take risks safely as part of an independent lifestyle, they have been reviewed and updated since the last inspection. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 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, 13, 15, 16 & 17 The quality in this outcome area is adequate. The judgement has been made using available evidence including a site visit. Opportunities are limited for residents to develop independent living skills and to participate in preferred activities in the community, which has the potential to cause isolation. EVIDENCE: Records showed that two residents attend day care for part of the week. One resident said that he enjoys day care. Another resident met with indicated that he also enjoys day care. A daily timetable for each resident was viewed. They showed that they have not been reviewed/updated for sometime. This must be done to ensure that residents are happy with their current routines. Residents preferred choice of activities at home and in the community were recorded in their care plans, however daily records showed little evidence of their participation in community based activities, it was clear that residents are Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 13 not being supported to take part in preferred activities that are set out in their plans of care. This has the potential to cause isolation. The Manager said that this was because of a recent shortfall in staffing skills and mixes, which has since been resolved by the recruitment of new staff members. The service must always provide an effective staff team with sufficient numbers and skills to support residents assessed needs. Records showed that all residents have family who visit the home whenever they choose. Discussion with the manager and care plans showed that two residents do not have keys for their rooms because of limitations. This information was recorded in their care plans. One resident had a key to his bedroom, he said he keeps hold of it at all times. None of the residents hold a key to the front door due to limitations. This information was recorded in their care plans. Staff were seen communicating and interacting well with residents. Residents were observed using all communal parts of the home freely. They were also seen occupying their own bedrooms at intervals throughout the visit. Staff were observed knocking before entering residents bedrooms. One resident said that he sometimes helps with the shopping, tidies his own room and helps to vacuum the lounge. Residents care files acknowledge that with a level of support they can participate in a variety of tasks and daily routines of the home, however daily records and observation did not evidence this. Staff were observed carrying out household tasks without the involvement of the residents, this was discussed with the manager and staff during this and the previous inspection visits. Menus were viewed. Examination of the kitchen showed a good stock of fresh, frozen and tinned foods were seen at the home. One resident said, “I like the food and I choose what I eat”. The manager said that residents are encouraged to eat meals in the dining room but if they wish eat their meals in the lounge or in their own rooms. One resident confirmed this during discussion with him. The manager confirmed that residents do not always help shop for food and that staff often go shopping without them. This was discussed with the manager who explained that it was because of previous staffing shortfalls. Residents must be given more opportunities to be involved in shopping for food and other household items. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 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 The quality in this outcome area is good. The judgement has been made using available evidence including a site visit. The health and personal care needs of residents are well met which ensures their wellbeing. EVIDENCE: Care plans recorded individuals preferred routines, likes or dislikes with regard to personal care. Details of how staff must provide individuals with support with personal care were available in good detail. The information, which has not been reviewed/updated for sometime, must be to ensure that resident’s health and personal care needs are fully met. One resident said, “I choose when to get up and go to bed and what to wear each day”. All residents were clean in appearance and appropriately dressed. Records showed that specialist advice and support is accessed for residents who need it i.e. speech therapists and physiotherapists. During interviews staff demonstrated a good awareness of the main principle of care, including privacy, dignity and respect. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 15 Records showed that residents are offered minimum annual health care checks and that these needs are well met, monitored and supported. All residents have been supported to attend GP appointments, dentists, chiropodists, hospital appointments and opticians. Details of appointments and outcomes were well recorded. Discussion with the manager and records showed that residents access health care services, which are located in the local community. Records showed that support and monitoring is consistent for one resident who has epilepsy. Staff showed good knowledge and understanding of his condition and how to manage it. Daily records that were viewed showed that residents health care is monitored and that complications and problems have been identified and dealt with appropriately. Medication and Medication Administration Record Sheets were examined, they were all in good order. Medication was stored in a locked cabinet that was fixed to the wall in the office. Records showed that medication is administered by staff that have undertaken the required training. Staff interviewed confirmed that they have undertaken medication training. The manager confirmed that due to their limitations none of the residents administer their own medication and it is unlikely they will ever be able to. A policy for the receipt, recording, storage, handling administration and disposal of medication was available at the home. A record of medication received and leaving the home was seen. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 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 quality in this outcome area is adequate. The judgement has been made using available evidence including a site visit. Residents are protected by the homes complaints and POVA procedures. Residents have limited access to their own money because of practices followed by the home. EVIDENCE: A complaints procedure was available at the home. A copy was on display at the main entrance of the home. The manager said that all relatives and representatives have been sent a copy of the homes complaints procedure. The procedure included details of how a person can make a complaint, the timescales involved and details of the Commission for Social Care and Inspection. A relative spoken with said that she was sent a copy of the homes complaints procedure and that she is confident about making a complaint if she needed to. A complaints book was viewed at the home. There were no complaints recorded in the book. During discussion staff confirmed their knowledge of the homes complaints procedure and showed a good awareness of it. A copy of the Local Authorities most recent Protection of Vulnerable Adults procedure was available at the home. Protection of Vulnerable Adults training has been undertaken by most staff, this was confirmed during discussion with them and by examination of training records. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 17 During interviews staff confirmed their knowledge of Protection of Vulnerable Adults procedures and appropriately described what they would do if they suspected abuse or following an allegation of abuse. Discussion with the manager and examination of records showed that the system currently used for managing residents finances (as described in standard 16) restricts resident’s access to their own money. This was discussed with the manager who provided written evidence that she has addressed this issue with her line manager with a view to support residents to open their own banks accounts, which they can access more easily. Resident’s money and records that were kept at the home were checked and found to be in good order. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 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, 27 & 30 The quality in this outcome area is good. The judgement has been made using available evidence including a site visit. Procedures and practices carried out in the home ensure that residents live in a comfortable, safe and clean environment, however their privacy is not fully met. EVIDENCE: A partial tour of the home was carried out. The home is of domestic style and in keeping with others in the Road. The home has several shared spaces, which include a lounge, a sitting room and a large kitchen/dining room. Residents were seen using these rooms during the visit. The home has a bathroom and a separate shower room on the first floor and a toilet on the ground floor. The locks on all bathrooms and toilets were checked. None of them were working. The locks must be repaired or replaced to ensure residents privacy. There is a staff sleep-in room on the first floor and an office on the ground floor. All parts of the house are accessible to all residents. None of the residents are wheelchair users. There were no hazards identified at the time of the visit. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 19 Policies and procedures relating the health and safety of the environment were available in the homes health and safety manual, which was in the office and easily accessible to staff and residents. A planned maintenance and renewal programme for the fabric and decoration of the home was seen. The outside of the home was checked. Both the front and the back gardens were generally well maintained. The exterior decoration was in satisfactory condition. All resident’s bedrooms were viewed, they were clean, tidy and furnished to a satisfactory standard. One resident’s bedroom showed some damage on parts of the walls and the decoration of another showed signs of wear and tear. The manager said that both bedrooms are due to be attended to. The rooms should be improved to enhance the comfort and dignity of the residents. Comments made by residents and relatives included: “I am happy with my room and all other parts of the home”. “The home is always comfortable, clean and tidy when I visit”. One of the walls in the lounge, which has recently been repaired, is awaiting painting. The sofas in the lounge were a little worn and stained in parts, the manager said that these are being replaced in the near future. This should be done to enhance the comfort and dignity of the residents. All other furnishings, fittings and equipment in the home were of good quality, and were domestic, unobtrusive and ordinary. Records showed that the required testing of systems and equipment has taken place as the required intervals. All parts of the home were clean and tidy. Policies for the control of infection were available at the home. A domestic style washing machine and dryer was situated in the kitchen. During interview staff demonstrated an awareness of high standards of hygiene and control of infection. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 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): 32, 33, 34, & 35 The quality in this outcome area is adequate. The judgement has been made using available evidence including a site visit. The home does not have an effective staff team to support residents assessed needs at all times. EVIDENCE: Examination of records and discussion with the manager showed that there has recently been a shortfall in staff skills and mixes at the home due to difficulties recruiting. The home recently had vacancies for a support worker and a deputy manager these posts have now been filled. The manager said that existing staff and casual staff have been covering the vacant shifts. The manager said that opportunity for residents to access the community has been limited due to the shortage of regular staff. This is because a number of residents require the support of two familiar staff when out and about because of their specific needs. The home must at all times provide the required number and skill mix of staff to support resident’s needs. A selection of staff files were examined. References for two staff were not available in their personal files, the manager said that the references for those staff are at head office. All the required information for staff must be kept at the home so that they are available for inspection to show that residents are supported and protected by the homes recruitment procedures. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 21 All other required information was included in staff files that were viewed during the inspection visit. Staff interviewed confirmed that they were police checked before starting work at the home, they received statements of terms and conditions of their employment and that they took part in an induction programme during the first part of their employment. The manager has produced a training and development plan for each member of staff, which identifies future training required for each person. A number of these were viewed. Planned training includes both mandatory and specialist training courses, for example, protection of vulnerable adults, first aid, communication and autism, epilepsy awareness, fire training, food hygiene, health and safety, medication, infection control and mental health awareness. The courses are linked to the homes service aims and to residents needs and individual plans. Copies of certificates confirming attendance on training courses were viewed in staff files. A learning and development schedule for the period April to July 2006 was viewed. It detailed the course name and provider, course description and when it is due to take place. Permanent staff interviewed were happy with the level of training provided. A casual member of staff who was interviewed was dissatisfied about not receiving any training she said that she carries out the same duties (except administration of medication) as permanent staff. This was discussed with the manager who said that she would raise it with the company. All staff working at the home must undertake training that is specific to the role that they carry out. During a telephone interview one resident’s mother was complimentary of the staff group. She made the following comments: “The staff are caring supportive and good at communicating about my son”. “All staff are respectful and very helpful”. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 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, 39 & 42 The quality in this outcome area is good. The judgement has been made using available evidence including a site visit. The home is managed in a way that ensures the health safety and wellbeing of the residents. EVIDENCE: The manager is due to attend an interview with the Commission for Social Care and Inspection for her approval as registered manager of the home on 30/05/05. The manager was positive and enthusiastic about improving and maintaining standards at the home. She has commenced and is progressing well with the National Vocational Qualification Level 4 in Care. The manager has undertaken training specific to her role and the aims and objectives of the home. Certificates confirming this were viewed. Comments made about the manager included: “She is approachable and positive”. “The manager is good at her job, she is fair”. “I get on very well with her”. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 23 “I know I can talk to her about anything and she will listen”. “The manager is very good with the residents”. Quality assurance and monitoring systems are in place at the home. Residents are involved in meetings were in accordance to their abilities are consulted about the running of the home. The manager said that questionnaires are distributed to resident’s relatives and representatives seeking their views about the home. Copies of these were viewed. As Part of the homes 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. Reports, which are produced following the visits, are being sent to the Commission each month as required. Health and Safety policies and procedures relating to the environment were available at the home. A number of certificates in safe working practice areas and equipment were examined. These were current for fire safety, gas, and portable appliances. Information provided in the pre - inspection questionnaire showed that all other environmental health and safety checks have been carried out at the required intervals. Discussion with staff and examination of records showed that they have undertaken training in areas of health and safety including: First aid, fire awareness, infection control and manual handling. A handbook, which contains the homes policies and procedures, was seen in the office some policies and procedures show that they have not been reviewed for some time this should be done to ensure that they are up to date and relevant. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 2 13 2 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 X X 3 X Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA6 Regulation 14(2) Requirement The needs of one resident must be fully assessed to determine the suitability of the placement. Residents must be involved in day-to-day aspects of live in the home. The broken locks on the bathrooms and toilets must be repaired or replaced. Residents must have bank accounts in their own name and address, and bankbooks and statements must be kept at the home. Staff files must include all the required information. The home must be appropriately staffed at all times. Timescale for action 09/07/06 2. YA8 12(2)(3) 09/07/06 3. 4. YA27 YA7 23(c) 20(1) 09/07/06 09/08/06 5. 6. 7. YA34 YA33 YA35 17(2)(b) 18(1)(a) 18(1)(b) 09/07/06 09/07/06 Arrangements must be made for 09/07/06 all staff working at the home to receive training specific to the needs of the residents and the aims and objectives of the home. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 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 YA40 Good Practice Recommendations The homes policies and procedures should be reviewed to ensure that they are up to date and relevant. Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Gladstone Road, 29 DS0000005237.V290766.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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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