Inspection on 23/08/07 for Glendyke Road 54

This inspection was carried out on 23rd August 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glendyke Road 54 02/03/09

Glendyke Road 54 23/08/06

Glendyke Road 54 25/02/06

Glendyke Road 54 09/12/05

Glendyke Road 54 18/11/04

Glendyke Road 54 11/06/04

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 Glendyke Road 54 54 Glendyke Road Allerton Liverpool Merseyside L18 9TH Lead Inspector Mrs Janet Marshall Unannounced Inspection 23 August 2007 09:30 rd Glendyke Road 54 DS0000057717.V340047.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 Glendyke Road 54 DS0000057717.V340047.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. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Glendyke Road 54 Address 54 Glendyke Road Allerton Liverpool Merseyside L18 9TH 0151 724 5053 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.c-i-c.co.uk. Community Integrated Care Mrs June Dunne Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 6th February 2007 Brief Description of the Service: 54 Glendyke Road is a care home registered with the CSCI to provide care for three adults with a Mental Health /learning disability. Community Integrated Care have been the registered provider for this service since December 2003. The home is situated in the Allerton area of Liverpool and is close to local amenities, bus and rail routes. The care home is a bungalow and all facilities for the service users and staff is situated on the ground floor. The home is accessible for wheelchair users and is generally well maintained. The fees for the home are £265.55 per week. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The last key inspection took place in August 2006 a further unannounced visit was carried out in February 2007 to check the progress of the requirements which were given as part of that inspection. All the requirements have since been met. This was a key inspection. The Commission considers 22 standards for Care Homes for Adults as Key Standards, which have to be inspected during a Key Inspection. The report has been put together using information gathered from a number of sources including information that the commission have received about the service since the last inspection and details provided in the Annual Quality Assurance Assessment (AQAA). The AQAA, which is in two parts, a selfassessment and dataset, has replaced the pre-inspection questionnaire. The document, which was sent out to, the service was completed and returned to the commission before the site visit took place. A number of surveys were sent out to people as part of the inspection but none of them were returned. The inspection also involved an unannounced visit to the home (site visit). Records that were examined, staff comments and observations made during the visit have also been used as evidence for the report. All the residents that live at the home have limited verbal communication skills so were unable to express their views and opinions about the service. However, a number of residents were case tracked. This process involved talking to staff, looking at the environment and a selection of residents records such as assessments, care plans and daily notes to get an idea about peoples experiences and to find out if they are receiving the care and support that they need and which have been agreed by their representatives. The manager Mark Jones was not on duty on the day of the site visit. Staff that were on duty assisted with the inspection, they were both very helpful. What the service does well: Available at the home are a number of detailed policies and procedures, which clearly described the processes for assessing and admitting new residents to the home. These ensure that people make the right choice about living there. Up to date care plans were in place for residents, which clearly set out how staff need to support residents enabling them to live independent, healthy, safe and enjoyable lifestyles. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 6 Staff were seen and heard treating residents in a respectful way. Their attitude and approach towards residents and each other ensured residents privacy and dignity at all times throughout the inspection. The home had in place procedures for responding to concerns and complaints and for ensuring that residents are safe from abuse, harm or neglect. The commission have not received any complaints about the home since the last inspection. Staff spoken with during the inspection said that they understand the homes complaints procedure and now how to make a complaint if they needed to. They knew who to talk to if they were unhappy about something and were confident that their complaints would be listened to and dealt with in the correct way. At least half of the staff team have achieved or are working towards a National Vocational Qualification in Care level 2 and above. Staff are involved in an ongoing programme of training, which is relevant to the work that they carry out. Staff showed a real committed to both mandatory and specialist training so that they have up to date knowledge of current good practice and law. A comprehensive detailed set of polices and procedures were available at the home. The polices provided clear information which help staff make the right decisions and take actions which are law and in the best interests of the residents. The procedures clearly described the steps that people need to take to fulfil the policy. A number policies and procedures have been reviewed and updated since the last inspection to ensure that they are relevant and up to date. People spoken with were confident that the home is managed well. Records that were examined at the home were well-organised, up to date and accurate ensuring residents health and safety. What has improved since the last inspection? What they could do better: Information about residents must be locked aware to ensure their confidentiality. Staff should provide residents with more opportunities to take part in the dayto-day routines of the home such as cooking and cleaning as a way of further promoting their independence. Resident’s personal money should be managed in a way, which allows them to access it more freely. The main bathroom needs to be refurbished to ensure the comfort and dignity of the residents. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 7 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. The summary of this inspection report can be made available in other formats on request. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 8 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 Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 9 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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures followed at the home ensure that people do not move into without knowing it is the right place for them to live. EVIDENCE: There have been no new residents admitted to the home since the last inspection. Information provided in the AQAA and discussion with a member of staff confirmed that the three people that live there have done for approximately 10 years. The AQAA explained clearly the processes, which are followed for assessing and admitting a new resident to the home. A detailed assessment of the persons needs would be undertaken by the service manager with the involvement of the prospective resident, their family/representatives and other relevant professionals including a social worker. The assessment helps people to decide if a persons needs can be met at the home and if is the right place for them to live A new resident would be introduced to the home over a period of time to ensure that the move is least stressful as possible to the person. Before moving in they would visit the home several times, to get to know the other residents, the staff and to become familiar with the environment. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 10 When a placement has been agreed, a care plan and risk assessments based on the pre – admission assessment would be developed to enable staff to meet the needs of the resident once they have been admitted to the home. There was a detailed resident guide in each of the resident’s bedrooms. The document, which was viewed during the site visit, describes the staff team, services and facilities available at the home. The resident guide needs to be updated to include recent changes to the management structure and staff team so that residents and their families/representatives have relevant and up to date information about the home. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Personal files contained detailed care plans which provide staff with good information about how to support residents to live independent and lifestyles, however the storage of information compromises residents confidences. EVIDENCE: An individual set of care plans and an essential lifestyle plan were available at the home for each of the residents. All plans were contained within each person’s personal file. Personal files also contained other information about the person for example medical notes, financial information, assessments and personal letters. Care plans, which were viewed as part of the inspection, visit clearly set out people’s lifestyle choices and their care and support needs along with clear instructions for staff about how best support them. Mobility, communication, personal and healthcare support were just some of the areas, which were covered in each persons care plans. Some care plans included photographs, which a member of staff explained helps residents to understand their care plans. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 12 Care plans showed that they have been reviewed and updated at regular intervals. All the people that live at the home have limited verbal communication skills, however they are encouraged and supported to make everyday choices and decisions by using other methods of communication such as sounds, body language, gestures and pictures. Available at the home was a book, which contained photographs of food. A member of staff said that the book is used to help residents choose the food they want to eat each day. The AQAA explained that other photographs are being collected and put into books to help residents make more choices about other things such as holiday destinations and activities. This was also confirmed during discussion with members of the staff team. One member of staff said they are in the process of putting together a picture book to help one resident choose a holiday destination for later on in the year. Discussion with staff, observations made during the visit and information provided in the AQAA showed that the staff team have built up a good awareness of each persons preferred methods of communication. Information about each persons preferred methods of communication were recorded in their own plan of care. The residents are not responsible for particular household tasks because of the nature of their disability. Staff promote service users right to choice and respect by the manner they engage with them. During the visit staff were observed talking to residents in a respectful way. Discussion took place with staff about how they could encourage and support the involvement of residents in general routines and daily living skills such as: cleaning and cooking. Examples included giving residents the opportunity to sit in the kitchen whilst staff are preparing meals allowing them to smell, touch and see the food, which is being prepared. Staff agreed to provide residents with such opportunities. Risk assessments were part of each persons care plan. A selection of risk assessments was viewed as part of the case tracking process. They showed that staff have the information that they need to support residents to take responsible risks as part of an independent lifestyle. Risks assessments included information about the action, which staff need to take to minimise risks and hazards so that residents can enjoy and take part in their preferred activity or choice. Risk assessments were also available for the use of equipment such as bathing aids and outdoor activities such as hydrotherapy. Although not on display resident’s personal files were kept in an unlocked drawer in the main lounge. The files, which contained a great deal of confidential information, must at all times be kept securely in the home to fully ensure residents confidentiality. Resident’s personal files were immediately transferred into a locked cabinet. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 13 Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given appropriate opportunities to enable them to live active and fulfilling lifestyle, however, current financial arrangements have the potential to restrict some of those lifestyle opportunities. EVIDENCE: The AQAA stated that resident’s lead very individual lifestyles and each engage in different community and leisure activities, which are appropriate to their needs and individual preferences. Information provided in the AQAA, discussion with staff and examination of a selection of residents daily records showed that they take part in a range of planned and unplanned activities and the staffing levels at the home are sufficient to allow residents to do this. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 15 Displayed on the wall in the office was a weekly planner which highlighted planned activities which residents are involved in as part of their weekly routines. Planned activities included hydrotherapy, aromatherapy, music sessions, day care, voluntary work, and shopping trips. A member of staff explained that one resident particularly enjoys rides out on public transport. The member of staff gave examples of recent trips, which included boat, bus, and train rides. The resident is also part of a voluntary dog walking scheme which he takes part in with the support of staff on a weekly basis. Displayed around the home were various photographs of residents enjoying activities at home, days out and holidays. Staff confirmed that each of the residents have had a holiday or have one planned this year. They confirmed that residents are fully involved in choosing and planning their annual holiday. One of the residents went abroad this year for a week with staff, another resident is also planning to go abroad. The use of case tracking and details provided in the AQAA showed that residents religious beliefs are respected and appropriately supported by staff as are important relationships with family and friends. Staff said that residents are free to receive visitors whenever they choose and they are all made welcome at the home. A visitor’s book, which was kept in the hallway, showed that people regularly visit the home. None of the residents are able to manage their own money. A member of staff confirmed that residents have bank accounts in their own names, which are held and managed by the company. The member of staff explained that residents have access to small amounts of their personal money, which is kept at the home and managed by staff. However if they require larger amounts a written request has to be made to the main office. This process can often take a number of days, which has the potential to restrict lifestyle opportunities for residents. It is recommended as part of this report that the management look other options, which are less restrictive so that residents are able to access their money more freely. Resident’s money and records kept at the home, which was looked at, were in good order. There is a dining table in the kitchen, which is mostly used by residents at meal times. However they have the option to use another dining table, which is located at one end of a large shared lounge. Food stores, which were looked at as part of the inspection visit, showed there was a good stock of fresh, frozen and tinned food items. The kitchen was bright and equipped with domestic style appliances such as a microwave and cooker. There was plenty of crockery, cutlery, pots and pans, which were of a good standard and in good condition. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 16 Available at the home was a record of all food provided to the residents. Staff explained that even though there is a planned menu alternatives are always available. Residents need some assistance at mealtime. During the visit staff were seen assisting residents with their evening meal. This was done in an unrushed and sensitive way. Discussion with staff and examination of a selection of records showed that residents special dietary needs are catered for and identified in their individual plan of care. Staff confirmed that residents are involved in the menu planning and accompany staff to do the weekly shopping for the home. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s physical and emotional health is closely monitored to ensure that they access appropriate care and support to promote their well being. EVIDENCE: Care plans provided detailed information about the type and level of personal and healthcare support that each person requires. The persons preferred routines with regards to personal care were also available in good detail. During Discussion staff showed a good awareness of and gave a number of examples of how they ensure that residents privacy and dignity is maintained and respected. “I always talk to the person when helping them with personal care” “I always close the door” “I always knock on doors before entering residents bedrooms” Each person had a care plan, which covered in detail their healthcare, needs and the support that they need to stay well. Records within this section showed that they are offered minimum annual checks and that there health is regularly reviewed, monitored and dealt with appropriately. As well as visits to Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 18 primary healthcare services such as dentist, opticians and doctors residents are also supported to attend specialist services. Records detailing the visits were available in good detail as was information about specialist health care needs and requirements. Where appropriate visits to the home by healthcare professionals are arranged. The service operates a key worker system to enable residents to develop to a closer relationship with a specific staff member particularly in the areas of health and personal care. The key worker is responsible for reviewing the resident’s monthly plan and to arrange healthcare appointments etc. for residents. During discussion a member of staff described clearly their role and responsibilities as a key worker. During this inspection visit all medication and medication administration records were examined. Medication and records were stored in a locked cabinet in the office. Discussion with staff and examination of records showed that staff have completed medication awareness training. A policy for the safe handling and administration of medication was availble at the home. A member of staff showed a good awareness of the homes medication polices and procedures. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has various policies and procedures, which aim to protect the residents from harm, abuse and neglect. EVIDENCE: There has been no complaints received by the Commission about the home since the last inspection. Information provided in the AQAA and examination of the homes complaints book evidenced that there have been no complaints made at the home in the last 12 months. The home had available a complaints procedure which included clear information about the stages and timescales involved in the process so that people are clear about how to make a complaint if they wish to. Discussion with staff and information provided in the AQAA showed that staff at the home are working with the speech therapist team to provide the information in a format which can be better understood by the residents. Discussion with staff showed that they are aware of the home complaints procedures and are confident about telling somebody if they were uphappy. The following comments made by staff supported this: “Yes I most definitly would make a complaint if I was unhappy about something” “Yes I know about the complaints procedure and understand it what I need to do” Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 20 A copy of the local authorities protection of vulnerable adults procedure was avaialbe at the home. Staff spoken with were able to describe confidently what action they would take if they suspected or evidenced that a resident was being abused. They confirmed that they had completed up to date protection of vulnerable adults training. Detailed in the AQAA were a number of other polices, procedures and codes of practice which are available the home and aim to protect residents from harm abuse or neglect, they include gifts to staff, recruitment of staff and Whistle blowing. Staff spoken with during the visit showed a good awareness of these documents. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a clean and comfortable environment, which is also free from hazards. EVIDENCE: The home is a spacious three-bedroom detached bungalow located in a popular residential area of Allerton, Liverpool. There is a good sized garden and patio area at the back of the house and a large driveway with off road parking for a minimum of two cars at the front. The home is in keeping with others in the area and is indistinguishable as a care home. The premises are fully accessible and fitted with aids and adaptations including wheelchair ramps to all entrances. Public transport links are close by. The main bathroom in the home provides toilet and assisted showering and bathing facilities. There are ongoing plans in place to refurbish the main bathroom. This is because the bathroom suite, fittings décor are old and showing many signs of wear and tear. The AQAA showed that part of the services plans for improving the environment in the next twelve months Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 22 includes the refurbishment of the main bathroom. A separate W.C facility is also provided and has good wheelchair access. The toilet and bathroom doors were fitted with over ride locks, which were in good working order on the day of the visit. The home provides a bath hoist to assist in the bathing of service users when necessary. There are plans to replace the bath hoist with a type of hoist that will further benefit the residents. Resident’s clothes are laundered and ironed by staff. The home has a utility room next to the kitchen, which is equipped with domestic style appliances such as a washing machine, dryer and iron. The home has a policy in relation to infection control and has adequate arrangements in place to ensure that clinical waste is appropriately stored and disposed of. All parts of the home appeared comfortable, clean and tidy and free from hazards. Cleaning routines followed at the home ensure that the environment is kept clean and tidy for the residents that live there. Pictures, ornaments and photographs were displayed around the home making it feel homely and personalised. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service ensures that staff maintain their knowledge and skills to promote service users well being and safety. EVIDENCE: The AQAA showed that there are six care staff and the manager working at the home. Discussion with staff showed that some of them have worked at the home for a number of years, during which time they have developed good relationships with residents. Observation of staff with residents indicated that they had a good rapport with them. Examination of a selection of staffing rotas and discussion with staff showed that the staffing levels at the home are good to enable residents to take part in activities of their choice and to support their individual activity programmes. Discussion with staff indicated that they are aware of their knowledge and skills limitations and if need be would seek advice from others with more specialised knowledge. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 24 The service has employed a number of new staff recently. The AQAA showed that the new staff are currently going through comprehensive induction training. The AQAA showed that approximately 50 of the staff have achieved an NVQ in care Level 2 or above and a number of others are working towards it. It also showed that each staff member has an individual training and development plan and up to date training records, which are kept, in their personnel files. There was an equal opportunities policy and procedure available at the home. The AQAA showed that the service employs people of various age, gender and ethnicity. A requirement was given as part of the last inspection to ensure that staff files included copies of two references. This is so that the manager has all the information they need to show that the person is fit to work at the home. Staff records were not looked at during this inspection because the manager who was not on duty at the time of the inspection locked them away. However the AQAA stated that all staff files have been reviewed and updated since the last inspection and contain two references, an enhanced CRB check, statement of terms and conditions supervision and training records. Discussion with staff on duty showed that staff were inducted into their role and within six months of starting their employment and they completed mandatory training in moving and handling, food hygiene, first aid and fire awareness. Staff spoken with commented that the training provided by the company is very good. Information provided in the AQAA and discussion with staff showed that they receive regular “one to one” supervision from the manager and a record is maintained of items discussed and regular staff meetings are held and minutes of the meetings are kept. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 25 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 & 42. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is managed to the benefit of the residents and staff. EVIDENCE: Mark Jones was appointed as the new manager of the home in July this year. The commission was notified in writing of this change. Records held by the commission show that he has obtained an application for approval as the registered manager of the home. The manager has completed his NVQ level 4 Registered Managers Award. The homes policies and procedures are developed centrally and forwarded to the home. The AQAA showed that the home has available all the policies, procedures and codes of practice which are required by the law. On display at the home was a current Public Liability Insurance certificate. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 26 Records that were looked at well maintained in the home and residents/representatives are able to access their records in accordance with the home’s policy on access of information. Resident’s records were not kept in a secure place as described in the Individual Needs and Choices section of this report. This compromises resident’s confidentiality. The health safety and welfare of residents are well protected this was supported by a comprehensive and well presented set of policies and procedures. The AQAA showed that the home have in place all the policies and procedures which are required by regulation for this service. It also showed that a number of them have been reviewed and updated since the last inspection. Reports, which are forwarded onto the commission each month, show that a representative for the home is carrying out regular visits to the home to check the quality of the service. The reports show that residents and staff are happy with all aspects of the home. Information provided in the AQAA and examination of a selection of health and safety records showed that the required health and safety checks have been carried out on the environment at the required intervals, for example fire system checks, gas and electricity checks and environmental risk assessments. A member of staff confirmed that the fire alarm system and water temperatures are tested weekly. Details provided in the AQAA and discussion with staff showed that they have completed training in areas of health and safety such as fire safety and first aid. Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 27 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 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 3 X 3 X X 3 X Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 28 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA10 Regulation 17 Requirement All information about residents must be kept in a lockable cabinet so that their confidences are kept. Timescale for action 23/09/07 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 YA27 Good Practice Recommendations It is recommended that the bathroom/shower room furnishings and fittings be updated to enhance the comfort and dignity of the residents. Residents should be given more opportunities to take part in the daily routines of the home such as cooking and cleaning. It is recommended that the management look other ways of managing resident’s money so that they can access it more freely. 2. YA8 2. YA16 Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Glendyke Road 54 DS0000057717.V340047.R01.S.doc Version 5.2 Page 30 - 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. 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