Inspection on 09/12/05 for Glendyke Road 54

This inspection was carried out on 9th December 2005.

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

The inspector found no outstanding requirements from the previous inspection report, but made 4 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 23/08/07

Glendyke Road 54 23/08/06

Glendyke Road 54 25/02/06

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 Lynn Sharples Unannounced Inspection 9th December 2005 09:30 Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Glendyke Road 54 Address 54 Glendyke Road Allerton Liverpool Merseyside L18 9TH 0151 420 3637 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) Community Integrated Care Limited Mrs June Dunne Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 18th November 2004 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. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There were three people living at 54 Glendyke Road at the time of the visit. The home did not know about the visit and took four hours. The inspector spent time with the service users and spoke to the one care staff on duty and the registered manager. What the service does well: What has improved since the last inspection? What they could do better: The registered person should produce an up to date statement of purpose that includes all the details listed in Schedule 1 of the Care Home Regulations. The registered person must ensure that bed rail assessments consider: the correct positioning of the bed rail, the use of bed rail bumpers or the risk of the Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 6 service user climbing over the rail. The registered person must ensure that adequate action is taken in relation to the identified issues identified in the bathroom. The registered person must ensure that 50 of care staff in the home achieve a care NVQ 2 award. The registered person must ensure that each staff member has an individual training and assessment profile and at least five paid training and development days (pro rata) per year. 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. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5 The homes Statement of Purpose and Service User Guide are good providing service users and prospective service users with details of the services the home provides. EVIDENCE: The Statement of Purpose should include all the details listed in Schedule 1 of the Care Homes Regulations 2001. The Service User Guide is well presented; it should be modified to reflect the change in staff. The inspector recommended that it be modified using a pictorial representation. The current service users have been resident at the home since 1995/1997. The inspector was informed that a service user admitted to the home would only be done so following an assessment of their needs undertaken by the service manager, home manager and any relevant professionals. Inspection of the two service user’s file indicates that each has an up to date care plan in place. The home is able to demonstrate that the service users needs are being met. Specialist services are accessed where appropriate and good records are kept in relation to any health care interventions. Information that has been provided to the inspector indicates that service users would have a phased introduction to the home according to their needs and preferences. Sample files inspected confirms that service users are provided with a contract that meets this standard. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 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): 6,7,8,9 Service users needs are reflected in their care planning and they are supported in making some decisions and taking risks as part of their lifestyle and routines. EVIDENCE: Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 10 The manager has developed care plans for each of the service users. Sample care plans inspected indicated that these were observed to reflect the needs of individual service users and provide good detail as to how any identified need is to be met. “Care package checks” are undertaken monthly by key workers. Of the three service users, two care files were inspected and care plans indicate that the manager formally reviewed these. Due to their needs service users are unable to be involved in the drawing up of care plans, although the manager and staff team are building up an awareness of their preferred methods of communication. Since the last inspection there has been no further progress in the developing of service user Essential Lifestyle Plans. Service users rights to make decisions are limited due to their levels of understanding. However, from discussions with staff and observation during the inspection it is evident that the staff team have built up an awareness of services users methods of communication and in consultation with professionals and relatives support service users in making some decisions affecting their lives. This could be greatly improved using a speech and language therapist to advise about the use of pictures to aid communication and choice. The staff where observed to interact with the service users in an inclusive atmosphere with the service user as the focus. From discussions with the staff it is evident that service users are supported in terms of taking responsible risks. Where there are identified risk staff have acted appropriately to minimise the risk. Bed rail assessments are in place, however these did not reflect risks in relation to the correct positioning of the bed rail, the use of bed rail bumpers or the risk of the service user climbing over the rail. The inspector recommended that the manager involve an occupational therapist in assessing the risk of the bed rails and bumpers. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Service users engage in community and leisure activities appropriate to their age. A daily diary should be in place to record what activities service users have done. Visitors are welcomed at the home and people do call in at the home. Dietary needs are well catered for with a balanced and varied selection of food available that meets service users tastes. EVIDENCE: Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 12 One service user accesses a day centre three days per week and undertakes daily living skills. The other two service users have begun to attend college one day per week. Staff at the home support the service user’s at college, where service users are provided with opportunities to participate in various types of activities including trips out. In reflection of the service users current needs and capabilities service users are not involved in education programmes. Discussions with staff on duty indicate that service users are provided with opportunities to be involved in the local and wider community. Service users have regular trips out to local cafes, eateries and pubs. Regular planned and unplanned trips are undertaken. Each service user has an activity plan in place and all the staff team have responsibility in relation to ensuring that service users have opportunities to undertake individual activities. Staff informed the inspector that each activity plan is used flexibly and may change according to circumstances. Activities undertaken include: day centre, visits to the local shops, aromatherapy, occasional meals out, board games, music sessions and watching T.V. The inspector recommended that a daily dairy be started that indicates what activities each service user has participated that day and if they enjoyed it. Again, with consultation of a speech and language therapist the activity plan could be pictorial and the service users could be offered a choice of activity when appropriate. Discussions with staff on duty and inspection of records indicate that service user’s family links are actively encouraged and facilitated by the staff at the home. The home has no restrictions in relation to sensible visiting times. During the inspection staff were observed to spend time interacting with service users and spending quality time with them. Staff did not speak exclusively to each other and the main topics of conversation focussed on the service users. Staff where observed to treat service users with respect and dignity throughout the inspection. Service users have unrestricted access to all parts of the home including the garden area. Each bedroom has an over rideable lock although due to service users levels of understanding and dexterity they are unable to access this facility. Due to their needs service users are limited in terms of being actively involved in daily routines. A menu is maintained and indicates that service users are provided with a balanced and nutritious diet. Service users have individual needs and the food provided reflects these needs. A pictorial representation of meals could help the service users to indicate a choice of preference each day. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20, There is a clear care planning system in place to provide staff with the information they need to meet service users needs. The health needs of service users are well met with evidence of some multidisciplinary working. The medication at this home is well managed promoting good health. EVIDENCE: Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 14 All of the service users require full support in relation to personal support, although the staff team encourage independence where possible. The Inspector was informed and observed during the inspection that the support provided to ensures service users privacy and dignity. A bath hoist is used to support service users according to individual service user’s needs. Service users are supported in choosing their clothes etc. and this is facilitated according to their personality and levels of communication. Service users receive specialist support from professionals according to assessed need. Each service user has a key worker and a co worker. The home fully supports each service user in relation to healthcare needs and arrangements are in place in order that service users receive chiropody, dental and optical services. Good clear records are kept in relation to any health care intervention or contact with health care professionals. Specialist health care is sought where appropriate. The home has a metal, lockable and secure medication storage facility bolted to the wall. Inspection of a sample of MAR records indicate that staff sign to indicate if medication has been administered to service users and there were no gaps apparent. The inspector was informed that all staff had undertaken medication training in December 2004, this should be updated again. A photograph of each service user is on file and a record of staff signatures is provided. The manager has obtained agreement from the service users G.P in relation to the administration of homely remedies. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 The staff team have a sound knowledge and understanding of Adult protection issues, which protects service users from abuse. EVIDENCE: The home has a complaints procedure in place that meets this standard. A copy of this procedure is also contained within service users personal care files. The inspector was informed by staff on duty that one complaint had been made since the last inspection. The home has a copy of the organisations whistle blowing procedure that includes contacting the CSCI within 24 hours. Most of the staff have undertaken the organisations five day induction programme that includes discussion in relation to adult protection and abuse. A copy of Liverpool City Council policy and procedures in relation to adult protection is held in the home for reference purposes. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,29,30 The overall quality of the furnishings and fittings is good The home is comfortable and creates a pleasing and pleasant environment for the service users to live in. EVIDENCE: Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 17 On the day of the inspection the home was found to be very clean and malodour free. A re decoration programme within the home has been completed which includes service users bedrooms, kitchen, hallway and communal areas. The carpets have still not been replaced with a type of floor covering that colour co ordinates with the redecoration of the house. Each of the service user’s bedrooms is individually and tastefully decorated and furnished. None of the bedrooms has a hand wash facility. The home provides toilet and assisted showering and bathing facilities. There are ongoing plans in place for the assisted bath to be replaced with a more appropriate type of assisted bath. A separate W.C facility is also provided that provides good wheelchair access. The toilet and bathroom has an over rideable lockable facility. During inspection of the bathroom/W.C the following was noted: a number of wall tiles have screw holes, the tiling has mould/mildew in a number of places. 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 service users. The home provides domestic style programmable laundry facilities that are situated in the utility room and includes a separate washer and dryer. The utility room has adequate impermeable flooring. The home has a policy in relation to infection control. The home has adequate arrangements in place to ensure that clinical waste is adequately stored and disposed of. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 18 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 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): 32,34,35 Staff morale is good resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. EVIDENCE: The home employs five care staff, of which two have achieved NVQ level 2, the other three are waiting funding to start their NVQ training. The home is awaiting a new member of staff to start work. The five care staff have undertaken the organisations five day induction training which includes training in relation to knowledge and conditions specific to the client group The manager was not able to demonstrate that the staff team had received sufficient training this year other than fire training and information technology. The CRB checks were examined and were found to be order. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 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): There is a clear care planning system in place to provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 20 The manager was appointed to manage the home in December 2003. She has seven years management experience, managing a mental health care home. The manager is currently undertaking the NVQ 4 and has two units to complete. Monthly Regulation 26 visits are undertaken and a report of such visits are forwarded to the CSCI. As a result of these visits the person carrying out the visit provides an action plan to the manager where necessary. Records held at the home indicate that the last monthly audit undertaken by the service manager was undertaken in October, the manager said that the November visit was undertaken and she is awaiting the paperwork. The manager has copies of the all aspects of the company’s policies and procedures. The manager has also devised and implemented numerous local polices and procedures relevant to the effective running of the home. Inspection of records maintained indicates that the fire alarm and emergency lighting systems were tested on the 1 September 2005 and the fire fighting appliances were tested in September 2005. The fire book indicates that the fire alarm and emergency lighting systems are tested regularly, this was two weeks out of date, and the manager addressed this immediately. All staff receive regular fire drills. A fire risk assessment of the premises was undertaken in March 2005. Health and safety risk assessments are in place. The inspector was informed that all staff have undertaken first aid training as part of their recent induction training, although no records were available for inspection in relation to updated staff training. Accident records inspected appeared satisfactory. Copies of the electrical and gas servicing tests were available and found to be satisfactory. Records displayed in the home indicate that the home has adequate and valid insurance cover in place. Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 2 3 3 3 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 2 3 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 X 2 X 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 2 X 3 2 X CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Glendyke Road 54 Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000057717.V270074.R01.S.doc Version 5.0 Page 22 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 YA1 Regulation 4 Requirement The registered person should produce an up to date statement of purpose that includes all the details listed in Schedule 1 of the Care Home Regulations. The registered person must ensure that bed rail assessments consider: the correct positioning of the bed rail, the use of bed rail bumpers or the risk of the service user climbing over the rail. The registered person must ensure that adequate action is taken in relation to the identified issues identified in the bathroom. The registered person must ensure that each staff member has an individual training and assessment profile and at least five paid training and development days (pro rata) per year. Timescale for action 06/01/06 2 YA9 14 17/12/05 3 YA27 23 05/06/06 4 YA35 18 05/06/06 Glendyke Road 54 DS0000057717.V270074.R01.S.doc Version 5.0 Page 23 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 2 3 4 Refer to Standard YA6 YA7 YA27 YA32 Good Practice Recommendations The registered person should ensure that each service user has an Essential Lifestyle Plan in place. The registered person should ensure that service users are involved in making choices and record instances when decisions are made by others, and why. The registered person should ensure that the bathroom/shower room furnishings and fittings be updated. The registered person must ensure that 50 of care staff in the home achieve a care NVQ 2. 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