Inspection on 19/01/06 for Glenside (10)

This inspection was carried out on 19th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 7 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Glenside (10) 25/06/07

Glenside (10) 17/01/07

Glenside (10) 10/07/06

Glenside (10) 13/07/05

Glenside (10) 19/07/04

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 28/09/2008.

CARE HOME ADULTS 18-65 Glenside (10) 10 Glenside Allerton Liverpool Merseyside L18 9UJ Lead Inspector Beate Roth Unannounced Inspection 19 January and 6 February 2006 09:00 th th Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Glenside (10) Address 10 Glenside Allerton Liverpool Merseyside L18 9UJ 0151 724 5994 9999 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) North West Community Services (Merseyside) Limited Mr Anthony Carroll Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th July 2005 Brief Description of the Service: 10 Glenside Close is registered to provide personal care to 3 people with learning disabilities. All rooms are at ground floor level. Service users have single bedrooms. There is a large bathroom, a separate toilet, a large living room, kitchen and laundry room. There is a staff sleeping-in room, which is also used as a quiet area for service users and provides access to the garden. Bathing and mobility aids are provided. There is parking space to the front of the premises and a small garden area. The home is situated in a residential area of Mossley Hill and is close to the city centre. There are small shops in close proximity to the home and a good size shopping centre fairly close by. The service users have a minibus and several of the staff are designated drivers. There is access to train and bus services. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place on 2 days and lasted 4 and a half hours. During the inspection time was spent examining records and policies and procedures and talking to the staff. A tour of the home was undertaken. Staff were observed delivering care to service users. The service manager was spoken with. What the service does well: What has improved since the last inspection? What they could do better: The statement of purpose needs to cover all the required information. The contracts/terms and conditions need to provide clearer information about what the fees payable include. The involvement of family, friends/advocate in supporting service users when drawing up the contract/terms and conditions is recommended. The instructions for the administering of medication need to be accurately recorded in order to fully support service users. Evidence must be available to show that staff, have had all the required recruitment checks in order to demonstrate that the staff working with service users are competent and suitable to care for vulnerable adults. A copy of the monthly responsible individuals representative reports on visits to the home must be sent to CSCI. A fire risk assessment needs to be made available. Service users would benefit from 50 of staff having completed a formal qualification in caring for adults with a learning disability. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 6 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. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 5 A full assessment would take place to ensure that a service user’s needs could be met. A service user guide is available for prospective service users to refer to. The contracts/terms and conditions could better support the interests of service users. EVIDENCE: There are several documents available, which, together cover the information required for the service user guide. The statement of purpose does not cover all the required information as listed in Schedule 1 of The Care Homes Regulations 2001. The service manager reported that this is currently being reviewed. There have been no new service users admitted to the home since the last inspection. New service users would be assessed by the manager for the home. The manager would visit a prospective service user where they are living. Information would be gathered from the service users’ carers, social worker and any other relevant agencies. An examination of an initial assessment pro forma indicated that all the information recommended in the National Minimum Standards for Care Home’s for Younger Adults is available. Since the last inspection the contracts between the service users and North West Community Services have been made reviewed. The reviewed contracts do not clearly state the services covered by the fees payable. All additional costs to service users are also not identified (for example, the contribution Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 9 toward the cost and use of the mini-bus). The contracts have not been signed. The service manager reported that family/advocates are in the process of being approached to support service users in drawing up the contracts, as appropriate. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 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 and 9 Service users needs are met by the care planning at the home that reflects the assessed and changing needs of service users. EVIDENCE: A sample of service user care plans were seen. These provide a lot of detailed information on the needs of the service users and provide clear guidance to staff. The plans seen had had a recent review. The records and a discussion with staff indicated that service users are assisted to make decisions about their lives in accordance with their abilities. Communication guidelines assist in this process. Records of service users likes and dislikes and preferences around daily living, such as what time they like to get up and the activities they enjoy also ensures service users choices are respected. Risk assessments are carried out for both personal and environmental risks. These indicate the support that service users need to safeguard their wellbeing and take part in activities. All risk assessments are reviewed regularly. Since the last inspection the risk assessment on the use of bed rails has been amended and includes the required changes. Agreement around the use of Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 11 bed rails with the service users families has been recorded. A daily record is being made that the bed rails are safe for use. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 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): 11, 12, 16 and 17 Service users have opportunities for personal development and to take part in appropriate activities. The daily routines support the needs of service users. EVIDENCE: The records and a discussion with the staff indicated that service users are encouraged to develop independent life skills such as washing and dressing and choosing clothes. Evidence was also provided to indicate that service users take part in age, peer and culturally appropriate activities. Records showed that service users visit shops, parks, local library and local pubs and restaurants. There is a local bus link with facilities for the disabled and the service users have access to a mini-bus. Discussions with the staff and observations confirmed that the home’s routines are flexible as much as possible. The records inspected indicated the support service users need in their daily lives in order to make choices and encourage independence. An examination of the menu records indicated that varied and balanced meals are provided. Care plans indicate service users’ dietary requirements and any Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 13 assistance with eating that they may require. Advice is obtained from a dietician if this is required. Staff encourage the service users to eat a balanced diet and they monitor diet and appetite in order to ensure their well being. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 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 and 20 The health needs of service users are met and personal support is given that meets their identified preferences and promotes their wellbeing. Improvements need to be made to the recording around administering medication. EVIDENCE: Records show that staff are provided with guidance around providing appropriate personal care to service users. This includes the preferences of service users. Training records show that staff have received appropriate training in providing personal care with dignity and around PEG feeding. Records show that service users are supported to attend healthcare appointments and have access to health care services when they are needed. The medication records and corresponding medication were examined and in general found to be in order. The instructions for one type of medication indicated that it is to be administered daily, this did not correspond to the actual administration that was occurring, which is as and when required. Medication is stored securely. Members of staff reported and records showed that they have been trained in the administration of medication. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 15 Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 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 and 23 Staff training and policies and procedures are in place to ensure that service users are protected from abuse and that their views are heard and appropriate action taken. EVIDENCE: There is a complaint procedure available. Staff reported that they elicit the views of service users in accordance with their abilities. Information is available to enable a complaint to be made on behalf of a service user by an advocate. The complaint procedure describes the stages of the complaint and the timescale for managing complaints. The staff were aware of the content of the complaint procedure and how to respond to complaints. The CSCI has not received any complaints about this service since the last inspection. There is a Whistle Blowing Policy and Liverpool City Council’s Adult Protection Procedures available. Staff are given training on induction on issues surrounding adult protection. A number of staff have received formal training on recognising and reporting all forms of abuse, it is planned that all staff will attend this training. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 17 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 and 30 The home is clean and generally well presented and provides a comfortable and pleasant environment for service users. EVIDENCE: The home is generally decorated to a high standard and is comfortably furnished. Some minor attention is needed to the decoration in the bathroom. The manager reported that this room has been identified for redecoration. Staff reported that the staff bedroom, which is also used during the day as a quiet room for service users is cold. A portable heater was being used at the time of the inspection. This was situated on the floor and could have posed a tripping hazard. This was removed at the time of the inspection. A risk assessment, indicating to staff the circumstances in which the portable heater is to be used, was available at the second visit to the home. The service manager reported that there has been a problem with the heating at the home and that Maritime Housing, who rent the property to North West Community Services Limited, have agreed to supply a new heating system. A tour of the home showed that the home was clean. The home smelt fresh. It is clear the staff are working hard to ensure good standards of cleanliness are maintained throughout the home. There are procedures for staff to refer to about hygiene and infection control. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 18 Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 19 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 and 35 Service users are supported by the number of staff available and the training staff have received, however, service users would benefit further if 50 of staff had completed formal training. The records held at the home do not provide evidence that service users are protected by the homes recruitment practices. EVIDENCE: The staffing rota showed that there is a minimum of two staff on duty during the day and evening with a third member of staff available for some shifts. Staff interviewed said that the staffing levels meet the needs of the service users and enable service users to take part in group and individual activities outside the home. At night there is one sleeping and one waking member of staff available. There are currently no staff vacancies. An induction programme is provided for staff. This covers training around manual handling, health and safety, food hygiene, first aid and the protection of vulnerable adults. Following this the staff files show that staff attend training courses relevant to the duties they perform at the home, such as training in PEG tube feeding, epilepsy management and medication management. Staff are then encouraged to undertake an NVQ in caring for adults with a learning disability. Steps are being taken to ensure that 50 of staff have undertaken this qualification. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 20 Two new members of staff have been employed since the last inspection. The references for one member of staff and the start dates and job descriptions for both staff were not available. The service manager reported that the records of staff recruitment are generally held at the head office of North West Community Services and that in the future the majority of recruitment records will be held there. In accordance with policy and guidance published by CSCI in November 2005, with the agreement of CSCI, providers who have a centralised human resources department can hold some recruitment information within this department as long as there is sufficient documented evidence at the home that all the required checks and references have been undertaken and there is an agreement with CCSI as to as to the criteria for accessing the records held at the human resources department. This arrangement has not been agreed with CSCI. . Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 21 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 and 42 The quality assurance systems in general promote the wellbeing of service users. Improvements need to be made to the fire safety systems at the home. EVIDENCE: The manager of the home has an NVQ Level 4 in care and management. The manager has had several years experience of working with adults with physical and learning disabilities. The manager has undertaken regular training to keep his knowledge and skills up to date. The home carries out regular quality assurance audits and the Service Manager visits the home monthly and also carries out a thorough audit of service users’ health and welfare, accidents, risk assessments both personal and environmental, and staffing levels. However copies of the audit report are not sent to the CSCI office as per regulations and a copy was not available at the home for inspection. A financial audit is conducted once a year by the parent company. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 22 The records of fire safety checks, fire drills, gas supply safety check, electrical wiring safety check, portable appliance safety check were seen and were in order. Training records showed that staff are in general, given appropriate training in safe working practices. A fire risk assessment that is specific to the home was not available. General information on how to carry out a fire risk assessment has been obtained. The records showed that fire safety training has not been provided to staff at the intervals recommended by the fire service of every 6 months for day staff and every 3 months for night staff. The manager reported that the fire drill is an additional method of providing fire instruction to staff. The names of the staff that took part in the drills were not recorded. A record of who is involved in the fire drill should be documented as this provides evidence that staff have received fire safety training Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 23 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 2 2 3 3 X 4 X 5 2 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 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 1 X X 1 X Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 24 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 YA1 Regulation 4, 5 Requirement The statement of purpose must cover all the matters listed in Schedule 1 of the Care Homes Regulations 2001 (previous timescale of 13/10/05 not met). The contract/statement of terms and conditions between the home and the service user must clearly state the facilities and services that are included in the fees payable and any additional costs to service users and what they are (previous timescale of 13/10/05 not met). The registered person must ensure that the instructions for the administering of medication are accurately recorded. The registered person must demonstrate that the required information in Schedule 4 of the Care Homes Regulations 2001 has been obtained in respect of staff to ensure their suitability to work with vulnerable adults (previous timescale of 13/07/05 not met). The registered person must ensure that the local CSCI office receives copies of the monthly DS0000025273.V277433.R01.S.doc Timescale for action 06/05/06 2. YA5 5 06/05/06 3. YA20 13 06/02/06 4. YA34 17 06/02/06 5. YA39 26 06/02/06 Glenside (10) Version 5.1 Page 25 6. YA42 23 7. YA42 23 responsible individuals representative reports following their visits to the home (previous timescale of 13/07/05 not met). The registered person must 06/02/06 ensure that fire safety training is provided to day staff on a 6 monthly basis and night staff on a 3 monthly basis. The registered person must 06/03/06 ensure that a fire risk assessment is completed (previous timescale of 13/07/05 not met). 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. Refer to Standard YA5 YA32 Good Practice Recommendations When drawing up the contract service users should be supported by family, friends/advocate as appropriate. 50 of staff (including agency) are to hold an NVQ 2 or equivalent. Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Glenside (10) DS0000025273.V277433.R01.S.doc Version 5.1 Page 27 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!