Inspection on 16/12/05 for Greenheys (52)

This inspection was carried out on 16th 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 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 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Greenheys (52) 19/02/09

Greenheys (52) 03/10/07

Greenheys (52) 15/08/06

Greenheys (52) 08/03/06

Greenheys (52) 20/10/04

Greenheys (52) 10/03/04

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 Greenheys (52) 52 Greenheys Road Wallasey Wirral CH44 5UP Lead Inspector Lynn Sharples Unannounced Inspection 16th December 2005 09:30 Greenheys (52) DS0000018890.V272649.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 Greenheys (52) DS0000018890.V272649.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. Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Greenheys (52) Address 52 Greenheys Road Wallasey Wirral CH44 5UP 0151 638 8248 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) Alternative Futures Limited Mrs Gail Alison Oxley-Pascall Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd March 2005 Brief Description of the Service: 52 Greenheys Road is registered with the CSCI to provide care for up to 5 service users within the category of Learning Disability (LD). Alternative Futures Limited operates and manages the home, a registered charity operating in the North West with the premises being owned by Alternative Housing Association. The home is a purpose built detached bungalow with a large garden, close to Central Park Liscard Wirral and is within walking distance of local shops. There is car parking at the front of the home. Communal areas comprise a large lounge, with doors to the garden, and folding doors to the adjacent dining room. Well-planned domestic style kitchen and separate laundry facilities are provided. The home benefits from having a bathroom with W.C and separate shower room with W.C on the main corridor leading to the bedrooms; There is a separate toilet next to the lounge. There are five single bedrooms each with a wash hand basin. Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. There were five people living at 77 Greenheys 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 two care staff on duty and the manager. What the service does well: What has improved since the last inspection? What they could do better: The registered person must ensure there is appropriate sleeping facilities for staff undertaking sleep in duties. In relation to the identified person and the issue of challenging behaviour the registered persons must in consultation with relevant professionals including mental health and any other identified professional ensure that risk assessments in relation to episodes of challenging behaviour contain greater depth of information in terms of the identified risks, the risk management strategies being put in place, the effectiveness of these strategies and any other information. All staff working in the home should be Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 6 trained in BILD accredited physical intervention. All staff should receive regular supervision that is recorded. 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. Greenheys (52) DS0000018890.V272649.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 Greenheys (52) DS0000018890.V272649.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): 2,5 The homes Statement of Purpose and Service User Guide are very good providing service users and prospective service users with details of the services the home provides enabling an informed decision about admission to the home. EVIDENCE: Information from the previous inspection indicates that there have been no new admissions to the service since December 1998. Documentation indicates referral information is incorporated in the company’s assessment document. Information is gained from the service user and all other interested parties. The statement of terms and conditions are in the Service User Guide, which is a well presented document. The homes Statement of Purpose is a well presented document that is easy to read. Greenheys (52) DS0000018890.V272649.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): 6,7,9 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: Sample inspection of care files indicate that well detailed information is in place in relation to service users needs and how those needs are to be met. Each service user had an up to date person centred plan. The Care Programme Approach (CPA) is in place for one service user, documentation showed that this was out of date; The manager should ensure that the assessment of the service user’s needs is kept under review and contact the relevant professionals. The manager indicated that service users and their families are encouraged to be involved in decision making processes. The inspector recommended that the home expand this and use photographs to aid the decision making process. Also, as identified during previous inspections there are evident issues of challenging behaviour in relation to identified service users, and how the behaviour impacts upon the identified service user, other service users and staff. In consultation with relevant professionals including mental health and any other identified professional risk assessments in relation to these Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 10 circumstances must contain greater depth of information in terms of the identified risks, the risk management strategies being put in place, the effectiveness of these strategies and any other information. Individualised guidelines are in place including risk assessments; some of these were out of date. Service users admitted to the home have a range of needs, some more dependent than others. Greenheys (52) DS0000018890.V272649.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. Visitors are welcomed at the home and people do call in at the home. Dietary needs of service users are well catered for with a balanced selection of food available that meets service users tastes and choices. EVIDENCE: Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 12 The home supports service users to access a range of community based activities and these are detailed in service users daily living plans. All activities carried out by service users have been risk assessed in relation to the service user and the wider community. The inspector was informed that service users are individually supported in terms of issues of challenging behaviour impacting upon other service users. The service users are provided with opportunities to be involved in community based activities. On the day of the inspection two service users went out for a walk. The service is able to demonstrate relatives/supporters are encouraged to be involved in continuing to support service users if it is appropriate. This information is held individual pen pictures and the commentary that describes ‘good and bad days’. The home has a lounge/dining room with bedroom accommodation being single occupancy this offers service users the choice to receive visitors in private or in the communal lounge. Flexible routines are maintained to promote independence and choice. During the inspection service users choice and routines were respected and facilitated including spending time in their rooms, eating meals communally or by themselves according to their wishes and preferences. Information provided on the day of the inspection indicates that a healthy diet is promoted. Meals are served within the communal dining room, although service users are able to dine alone according to their preferences and routines. The inspector recommended that the meals eaten by the service users are recorded to ensure that the service users are provided with a healthy diet. Greenheys (52) DS0000018890.V272649.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): 18,19,20,21 The health needs of service users are well met with evidence of some multidisciplinary working. The medication at the home is well managed promoting good health EVIDENCE: Personal care tasks are undertaken gender appropriate where possible. There are appropriate arrangements in place to ensure that personal care tasks are undertaken with privacy and dignity. Care planning records and guidelines in place indicate that service users independence is promoted. Discussions with staff and inspection of sample care records indicate that service users health care needs are being met. However, the inspector recommends that appointments to health professionals are recorded in the personal files and not just in the daily diary. Inspection of sample medication records and storage facilities indicates that appropriate arrangements are in place in relation to this standard. However, there were excess stock of medication, the manager said that this would be returned today. Issues regarding covert administration are appropriately recorded with the signed consent of the service users G.P. In the personal files there are details of agreed funeral arrangements for each service user. Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 14 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: Information provided during previous inspection indicates that an appropriate complaints procedure is in place that meets this standard. No complaints have been recorded in relation to the service. Information provided during previous inspection indicates that the home has a detailed policy and procedure with regard to the protection of vulnerable adults and the procedure for whistle blowing by staff. During this inspection the inspector interviewed a staff recently appointed. The staff member was aware of the home whistle blowing procedures and had undertaken adult protection training as part of their initial induction. On the day of the inspection the two staff left in the house were not trained in physical intervention techniques. The home should have details of the accredited physical intervention training that is used in the home. Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 15 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): 24,25,30 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: The home has been purpose built and adapted over years to meet the needs of the service users. The home provides a comfortable environment and is overall well maintained and furnished. Oil heaters are used to supplement existing heating, which does not provide adequate heating for the home. The inspector recommended that these were included in the discussion the manager has on the visits by the responsible person and included in the risk assessments. The dining room needs decorating as the hatch between the kitchen and dining room has been plastered. The home provides a secure, well-maintained and good size rear garden. Some of the bedrooms inspected were pleasantly decorated furnished and have personalised. One bedroom requires redecorating. Areas of the home inspected during the inspection visit were clean and tidy and free from offensive odours. Support workers carry out both domestic and catering duties as part of their role. Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 16 Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35,36 Staff morale is very good resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. EVIDENCE: The service provides a high level of staff support. Generally three staff are on duty during the day, with two staff one waking and one sleep during the night time periods. The home has 9 care staff, one manager and one 15 hour vacancy, which is covered in house. Two of the care staff have completed the NVQ level 2 and two staff have started the NVQ level 2. There is a very low record of sick leave. Staffing levels were recently increased to meet the changing needs of one service user. The staff team records indicate that the home operates a robust recruitment policy. The staff team have not received 5 days training and would benefit from specialist training in epilepsy. The records indicate that the last individual supervision the staff members received was in May, this year. Not all the staff team have received training in physical intervention techniques. On the day of the inspection two staff that were not trained in physical intervention were left in charge in the house with three service users whose behaviour challenges. The requirement from the last inspection in relation to the staff sleep in arrangements remains unmet. Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,39,42 The complaints process in the home is good with complaints information available to service users. EVIDENCE: The home currently does not have a registered manager. The manager is submitting the paperwork to CSCI to register as a manager. The manager has the NVQ 4 (managers award). Monthly monitoring visits are undertaken and a report forwarded to the CSCI. Safety certificates in relation to this standard were found to be in place and up to date. Records indicate that arrangements are in place to ensure that staff receive appropriate fire drills and fire training. However, arrangements should be in place to ensure that a record is maintained of the content of the fire training/instruction staff received. Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 19 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 X 3 X X 3 Standard No 22 23 Score 3 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 2 3 X 2 X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 2 X X X X 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 2 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Greenheys (52) Score 3 2 3 3 Standard No 37 38 39 40 41 42 43 Score 3 X 3 X X 3 X DS0000018890.V272649.R01.S.doc Version 5.0 Page 20 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 YA33 Regulation 23 Requirement Timescale for action 16/01/06 2 YA9 14 3 YA23 12 The registered person must ensure there is appropriate sleeping facilities for staff undertaking sleep in duties. An adequate plan for proposed arrangements in relation to this aspect should be submitted to the CSCI. (This requirement remains outstanding, timescale 20/10/04). 16/01/06 The registered person must ensure that in relation to the identified person and the issue of challenging behaviour the registered persons must in consultation with relevant professionals including mental health and any other identified professional ensure that risk assessments in relation to episodes of challenging behaviour contain greater depth of information in terms of the identified risks, the risk management strategies being put in place, the effectiveness of these strategies and any other information. The registered person must 06/03/06 ensure that all staff working in DS0000018890.V272649.R01.S.doc Version 5.0 Greenheys (52) Page 21 4 YA36 18 5 6 YA6 YA26 14 23 (2)(d) the home are trained in BILD accredited physical intervention. The registered person must ensure that all staff receive regular supervision that is recorded. The registered person must ensure that the CPA review is up to date The registered person must ensure that one of the service users bedrooms is redecorated. 06/02/06 06/02/06 20/03/06 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 YA32 YA35 YA19 YA24 Good Practice Recommendations It is recommended that the staff should receive regular training in specialist training in challenging behaviour, physical intervention and epilepsy. It is recommended that each staff member has a least five paid training and development days (pro rata) per year. It is recommended that appointments to health professionals are recorded in the personal files. It is recommended that oil heaters are included in any risk assessments and that the central heating in the home is reviewed. Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 22 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 Greenheys (52) DS0000018890.V272649.R01.S.doc Version 5.0 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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