Inspection on 08/03/07 for Lethbridge Road

This inspection was carried out on 8th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Excellent. 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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lethbridge Road 06/01/06

Lethbridge Road 10/05/05

Lethbridge Road 30/09/04

Lethbridge Road 20/04/04

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 09/07/2008.

CARE HOME ADULTS 18-65 Lethbridge Road 2 Lethbridge Road Southport Merseyside PR8 6JA Lead Inspector Paul Kenyon Key Unannounced Inspection 8 and 12th March 2007 11:45 th Lethbridge Road DS0000005309.V315858.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 Lethbridge Road DS0000005309.V315858.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. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Lethbridge Road Address 2 Lethbridge Road Southport Merseyside PR8 6JA 01704 531385 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) lethbridge@autisminitiatives.org www.peterhouseschool.org Autism Initiatives Mrs Jacqueline Christine Emmett Care Home 7 Category(ies) of Learning disability (7) registration, with number of places Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 7 LD Date of last inspection 6th January 2006 Brief Description of the Service: The home has places for up to seven adults with a learning disability, specifically those with Aspergers syndrome. Formerly it was an assessment centre for people with Aspergers syndrome yet this has been changed since the last inspection and now the service offers a permanent residence to individuals. Aspergers syndrome is on the Autism Spectrum, but is usually a high functioning condition. The company running the home is a charity, called Autism Initiatives. Each resident has their own bedroom and share 2 lounges, a kitchen and three bathrooms. The home is on Lethbridge Road, which is off Scarisbrick New Road, in Southport. There are several buses that run along Scarisbrick New Road to Southport, Liverpool and Preston. There is a mainline train station in Southport town centre. The home is ten minutes by car or bus from Southport town centre where there are a wide variety of shops, bars, and leisure activities. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first key inspection to be held at Lethbridge road this inspection year (April 2006 to June 2007). The inspection was unannounced with the service not being told that the inspection would take place beforehand. The first day of the inspection included a tour of the premises, examination of records relating to the support provided to residents as well as interviews with two residents and two members of staff on duty. A further visit was made to enable interviews with two other residents to take place. Comments made by staff and residents are included within this report. In addition to his, comment cards were sent to families although their views were not available at writing of this report. National Minimum standards relating to younger adults were used to assess the standard of support provided by the service. Fees charged by the service currently range from £1372.56 to £2611.92 per week. What the service does well: The service is very good at ensuring that the needs of prospective residents are identified through the assessment process before the individual comes to live within the home. The service is very good at producing clear care plans that are reviewed more frequently than is required and fully involve the resident in this process. The service is very good at enabling residents to make decisions about their everyday lives. The service is very good at enabling residents to pursue their preferred daily activities and providing the individual support where necessary. The service is very good at upholding the rights and responsibilities of residents The service is very good at ensuring that residents are able to plan and prepare their own meals as independently as possible. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 6 The service is very good at ensuring that medication systems are safe and will empower individuals to take responsibility for their own medications when it is safe and appropriate. The service is good at supporting residents to maintain contact with the local community and in assisting them to maintain contact with their families and friends. The service is good at identifying the level of support required by residents in their daily lives and ensuring that individuals are as independent in doing this as possible. Residents are provided with the information they need to make a complaint about the service and have the opportunity as a group or as individuals to raise complaints with the staff team. The operating organisation takes the role of investigating complaints seriously. Residents are protected from abuse through a number of policies and procedures in place. A recommendation is raised in respect of the whistle blowing procedure issued to staff. The service is good at maintaining a clean and hygienic environment for residents and involves residents in this process as much as possible. Residents benefit from being supported by a staff team who are aware of their specialist needs and who communicate effectively with residents in order to support them. Residents benefit from being supported by a trained staff team who in turn are supervised as part of their roles. Residents receive a service, which is well organised and focussed on their needs. Residents benefit from a service that will examine the quality of the care its supports on a regular basis and involve residents in this process. The health and safety of residents is promoted. Comments by residents and staff included: ‘I feel that staff will get a doctor out if I am not well’ ‘ I am aware of monthly support plan reviews and I am involved in this’ ‘I do allsorts of activities: day centre, hair and beauty, gym’ ‘You do what you need to do’ ‘I can choose what I want to do, I have been out shopping, I do an activity rota on a Sunday for each week’ ‘If I had a complaint I would go to the staff and I am happy it would be taken seriously’ Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 7 ‘I feel safe at the moment-, staff are perfect, the best, best I have ever had ‘I am happy here at the moment’ ‘I feel ok at the moment, staff are supportive and very helpful’ ‘I work three times a week as a volunteer and I have got a certificate. I enjoy it, it gets me out and I feel a sense of achievement, I see my dad and go out with him. I use buses and taxis and staff let me get on with what I want. Meals - I prepare them myself and they encourage me to eat healthily. I self medicate, staff suggested it not me, I am happy with that. We have a monthly meeting, I would see the manager if I had any complaints-I am comfortable with staff, staff are ok’ ‘I have a bank account and I can decide what I want to do. I feel safe here, staff listen to me. I know about my support plan and I meet with keyworkers’ ‘I have my own bank account and feel safe with no worries, and I talk to staff. I know about my support plan and meet with my keyworker What has improved since the last inspection? What they could do better: The organisation must ensure that repairs are responded to consistently so that any backlogs in the maintenance of the home do not compromise the safety or comfort of residents. The service must ensure that proof of identity of staff is included within personnel records Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 8 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. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 9 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 Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 10 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 excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from having their needs identified prior to them coming to live at Lethbridge Road EVIDENCE: One person has come to live at Lethbridge Road since the last inspection. Assessment information relating to this person was examined. Assessment information included an assessment gained from the Local Authority as well as an assessment completed by the organisation. This was completed in April 2006 prior to admission and includes reference to behaviours, daily skills, and leisure and community activities. The Local Authority assessment contains general information in relation to needs with the organisations assessment provided a more detailed account and is more geared to the individual needs of the person. All assessments were received prior to the person coming to live in the home. In turn all aspects of the home’s own assessment was linked directly to this person’s support plan. Lethbridge Road DS0000005309.V315858.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 and 9 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from being given the opportunity to contribute and comment on how support in provided to them and can influence this. Residents are provided with the opportunity to make decisions about their lives and are consulted on this. Residents have all risks that they face through their daily lives identified and reviewed regularly. EVIDENCE: Support plans for four residents were examined. Interviews with service users confirmed that all were aware of the fact that they had a support plan although did not necessarily recognise it by that name. All confirmed that they Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 12 have monthly meetings with keyworkers on an individual basis and all believed that this was useful to them. As a result, support plans are reviewed monthly and involve the service user. Evidence was also available suggesting that these reviews occur on a monthly basis and that a general review including other professionals involved in their support take place annually. The support plan of the most recently admitted resident was examined. The contents of the support plan were linked directly to the initial assessment carried out. The Support plan is clearly outlined and includes reference to those areas where support is needed, for example, social skills in the wider community and issues with support in domestic tasks. In contrast, a support plan relating to another individual reflected the person’s imminent move from the service and this was indicated by the details of the support needed which were more centred around the sustaining of independent life skills. As a result, the content of support plans are linked to the progress that individuals have made and their future aspirations. Two residents were asked about the degree to which they are able to make decisions. All confirmed that they were able to do this and that staff supported them in whatever they wished to do. Monthly keyworker meetings enable residents to state their aspirations. All residents have family and relatives yet there is a difference to the extent this contact can be practically maintained. One person has family yet they do not live locally. It is recommended that this person is provided with access to advocacy services. Two residents were able to confirm that they have their own bank accounts and manage their own finances. There are no limits to the activities that people pursue at present. The majority of residents receive one to one support during the week. All residents confirmed that they have regular meetings and this was evidenced through recorded minutes. The meetings suggest that residents are enabled to set the agenda for the meeting and as a result are provided with the opportunity to make decisions for themselves. Risk assessments for three individuals were viewed. These are divided into those risks which the person faces in relation to their assessed needs e.g. the issues they may have with socially interacting with the general public while pursuing an independent lifestyle. The risk assessments then go on to outline the risks faced in individual activities pursued such as cooking or leisure activities. The assessments then go on to outline potential risks within the home environment. As a result all aspects of risk are accounted for and are done in an individualised manner. All risk assessments are reviewed monthly. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 13 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 and 17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents benefit from being able to pursue education or occupation in line with their wishes and are able to have significant access to the community. Residents benefit from being able to maintain contact with their families and also benefit from having their rights respected. Residents are significantly involved in the planning and preparation of their meals. EVIDENCE: Evidence was available to suggest that all residents plan their preferred activities on a weekly basis. This was confirmed through discussions with residents as well as examining the actual plans. Copies are made available to staff for reference. As a result, the education and occupation component is included within these activity plans. Some residents attend a day service, Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 14 some more than others. Two residents were asked about this service and both confirmed the activities they do there and that they enjoyed it. One individual only attends a couple of times a week yet the activity plan includes those activities, which include one to one support with staff. One resident currently pursues voluntary work and has obtained a certificate to confirm the number of hours he has done with this. He views as enabling him to obtain permanent work in the future. He carries out this work independently. The home in located in an area of Southport close to transport and other local facilities. Activity plans suggested that community links for residents are significant and in many cases, residents are able to find their way around the town with staff support where applicable. The suggestion is made through records that rather than individuals not being able to access the community themselves, it is more staff support required in the social interactions that individuals have to make as part of community life. This is also reflected in risk assessments. All residents have contact with their family and confirmed that they are able to contact the on a regular basis. One person’s relative lives some distance and is not able to maintain contact on a regular basis. It is recommended that advocacy services are made available to this person. All residents are expected to pursue their own daily routines. This is done in a number of ways. Firstly, each resident devises activity plans for the week and this was evidenced. In addition to this, there is an expectation that residents will cook their own meals (with support where applicable) and will launder their own clothes. This extends to the cleaning of their rooms and this is included in support plans. All residents have a key to their rooms. During discussions with the Inspector all residents had the choice to speak alone or with staff support. Two wanted to speak with staff present and two wished to speak on their own, in this way their privacy was upheld. The nature of the support provided is such that it is the interactions with staff that are crucial for residents. It was noted that staff spend a significant amount of time interacting with residents and gaining their views. Evidence was available to suggest that staff prompt residents especially when they interact with others. Activities are such that there is the scope for them to join with others in activities yet there is a suggestion that activities are preferred to be undertaken on their own or with staff support and this is respected. All areas of the home are open to service users. There is currently no need for residents to rely on aids such as guide/hearing dogs or other aids. There is an expectation that each person plans meals and that they prepare their own meals. Some need more staff support than others. As a result each person plans menus and storage arrangements in the kitchen enable each person to shop for him or herself and plan their meals as they wish. One resident confirmed that they had been shopping and had planned their menus Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 15 in advance. The only support the home provides is the provision of cooking facilities as well as a dining room. The kitchen is domestic in scale and there is an emphasis on healthy eating, which is incorporated into support plans. Progress in this area is recorded within daily records. There are set times for the preparation of meals yet these are not designed to be restrictive. The intention is to enable residents to receive the one to one attention they require in such tasks so that progress in this can be effective as possible. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 16 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 and 20 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents are supported in an appropriate manner. The health needs of residents are met. Medication systems are safe and empower residents. EVIDENCE: No residents receive direct personal care. The nature of the service is such that it provides emotional support and focussing on enhancing the life skills of individuals. This is reflected in support plans. All residents were asked about the level of support they received from staff and all were happy with it. All routines are flexible with the exception of meal times. Evidence was available to suggest that there is involvement in the support of residents from consultants who review medication on a six monthly basis. A key worker system is in place and all residents have designated key workers. Meetings between residents and key workers about their support occur monthly as evidenced through records. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 17 All residents were asked about their current health. All residents stated that they were well at the moment but confirmed that if they were needed, doctors or other professionals would be contacted to meet their health needs. One resident stated that he had a health issue of late that required him to visit the hospital and staff supported him to attend any subsequent hospital appointments. All residents have health records, which confirmed that a variety of health checks had been undertaken including visits to dentists, chiropodists and opticians. Generally service users are supported by staff in attending health appointments. As mentioned, a consultant psychiatrist will review all medication on a six monthly basis. The writing of daily records assists in collating information in respect of health issues. Medication is stored in a secure and lockable facility. A monitored dosage system is in use. All medication records were examined and had been signed for appropriately. Records also indicate that all medication is receipted. One person self medicates at present. He stated that the idea had not occurred to him and that staff had suggested it yet he is happy with this. This move evidenced the degree of independence given to residents and the preparation being made for his person to move into more independent accommodation. All staff have received medication training although further training is planned and notices in the home during the inspection confirmed this. A consultant on a six monthly basis reviews all medications. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 18 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 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from having the information they need to make a complaint if they wish and feel confident that the staff team will address any concerns. Residents are protected from abuse although staff are not provided with a complete procedure for reporting concerns. EVIDENCE: Interviews were held with four residents in total. All were asked if they knew what to do if they had a complaint. All stated that they had no complaints at present but suggested that they would talk to staff about any concerns and felt that the staff would help them. A complaints procedure is available as well as a complaints record. There has been one complaint made since the last inspection, which the Commission from Social Care Inspection were made aware of. The complaint outcome is pending yet evidence had been made available to suggest that the organisation has investigated the matter as thoroughly as possible. The Acting Manager has obtained Local Authority procedures relating to the reporting of allegations of abuse from all Local Authorities who fund current residents. Staff have been on abuse awareness training and this is included in the training programme for the first part of 2007. The training records and Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 19 certificates of two staff who were interviewed confirmed that they had been on this training. Staff asked about the whistle blowing procedure. Both staff members confirmed that they were aware of it and one member of staff was able to direct the Inspector to the procedure. It was noted that the procedure makes no reference to the role of the Commission for Social Care Inspection. It is recommended that the role of the regulator in acting as an external agency for investigation is included within the procedure. No residents at present display any verbal or physical aggression as confirmed through support plans yet staff have received training in dealing with this and this is included within the training programme. Four residents interviewed and asked if they felt safe in the home all confirmed that they do. All residents have a Positive Intervention Support Plan, which outlines any issues with respect of the potential interventions needed by staff in respect of residents’ behaviours although these are not relevant at present. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 20 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident live in a home live and pleasant environment although responses to repairs are inconsistent. Residents live in a clean and hygienic environment. EVIDENCE: A tour of home was undertaken. There is sufficient communal space within the building and the exterior of the home blends in with the surrounding buildings and there is no indication that the service is a registered care home. The interior of the building was noted to be very clean and free from any offensive odours. The only odours detectable were the smell of cooking. A domestic member of staff is employed within the home and there is an expectation that residents will be involved in household tasks. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 21 The Laundry contains industrial style appliances and is a well-organised facility. Again there is the expectation that residents will attend to their own clothing as evidenced by a rota available. Decoration in the home is to a reasonable standard. There is no indication that the home may receive any future refurbishment. The need for a refurbishment plan is raised as a recommendation in this report given that some areas are beginning to look tired in appearance. All residents are able to mobilise independently within the home and there is no need for passenger lifts or other aids and adaptations. The location of the building is such that it is close to local facilities and public transport routes. Access is available to a large garden area to the rear of the home. Once repairs have been identified they are recorded with details of date reported, the nature of repairs and the date they have been addressed. It was noted that responses to repairs had been erratic with some repairs reported in November 2006 still outstanding. Other records suggested that reminders for these repairs are re-reported by staff although an overall picture of inconsistent response to these repairs remains. This is raised as a requirement in this report. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 22 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 and 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from being supported by a staff team who are focussed on the needs of residents, are well trained and supervised. Recruitment systems are in the main satisfactory although work is required to ensure that all documentation relating to staff is available. EVIDENCE: Four residents were asked about the level of support provided to them by staff. All stated that they were happy with the help that staff gave them. One resident is about to relocate to more independent living. He stated that he had enjoyed his time at Lethbridge and that he was pleased with the progress he had made and that staff had helped him in every way. All residents confirmed that they have individual keyworker and keyworker meetings, which serve to enable residents to discuss aspects of their care as well as their support plan. Again residents said that staff listened to them at these meetings. Interactions throughout the inspection between staff and residents were positive. Staff Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 23 adopt a friendly approach to residents but will intervene to remind residents of issues such as appropriate interactions with others and organisation. Training records confirmed that staff had received training in autism spectrum disorder as well as Aspergers and certificates confirmed these. In addition to this, further training was included in the forthcoming training programme and reflected the main purpose of the organisation to provide support to individuals with autism and other related conditions. The positive attitude of staff was confirmed through staff interviews. One member of staff confirmed that the best thing about working in the service was that it was good to see individuals’ progress. This was also the view of another member of staff. It was clear that staff are a key point of reference for residents and staff are able to give the practical advice that is needed. Staff interviews confirmed that they have attained NVQ Level 2 and have the opportunity to progress onto Level 3. Staffing levels are maintained despite some of staff team having left since last inspection and vacancies especially at deputy manager level remain although steps are being taken to recruit at these levels Three personnel files were viewed during the inspection. In the main these are in order yet no information to confirm the identity of staff was available. This is raised as a requirement in this report. All personnel records are securely and confidentially stored on site in the office. The organisation has a training department. A training calendar has been produced for the initial part of 2007 and includes topics such as Autism Spectrum Disorder awareness, protection of vulnerable adults, medication training as well as mandatory training. Medication training has been arranged for the forthcoming weeks and this has been advertised to all staff. Training records are retained within the home and these indicated that mandatory training occurred as well as specialist training linked to the needs of residents. The Acting Manager explained that she is currently matching up that training which staff need with the training available within the training plan. This indicated that the training needs of staff are identified and that the organisation as a whole is able to provide this training through the training department. In respect of supervision and appraisal, staff interviews confirmed that they receive regular supervision as well as appraisals. All supervision records are stored away securely. The Acting Manager in turn is supervised by her line manager. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 24 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 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents receive support form a service that is well managed with the Acting Manager aware of her responsibilities under national minimum standards. Residents benefit from being involved in steps to assess the quality of service they receive. The health and safety of residents is promoted. EVIDENCE: The current Manager is in an acting capacity given that she has not yet applied to the Commission for Social Care Inspection for registration. It is understood that the submitting of an application is imminent. The previous Registered Manager has left the home since the last inspection. The Acting Manager is Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 25 currently the only supervisory staff member within the home. There are vacancies for two Senior Support Workers and interviews for these posts are to take place in the near future. Administration systems were noted to be well organised and in place. One member of staff said: ‘The Manager has strong points and leads by example’ Quality assurance carried out in a number of ways. These include, monthly visits by a representative of the organisation and an annual quality assurance visit. The report relating to the annual visit has been made available to the Inspector. Quality is also maintained through the use of resident meetings held on a monthly basis which enable residents to provide a view of the support they receive as well as planning any activities etc in the home. This was evidenced through the examination of meeting minutes form the past few months. The service co-operated fully with the inspection process. All records were available and the opportunity was there for the Inspector to speak with residents and staff alike as well as gaining access to all parts of the home. In respect of health and safety, a judgement on the degree to which the health and safety of residents is promoted was gained through the examination of a number of records. Training records confirmed that staff have attended health and safety training, that this had been included in the training calendar for the first part of 2007. Fire systems have been checked including alarms, emergency lighting, fire extinguishers and the holding of fire drills. The premises include radiators that have been covered and all risks with health and safety in the home have been identified through assessments completed on each individual living there. Accident records were appropriately completed. The building has received checks to its electrical wiring, electrical appliances and gas systems. Certificates confirmed the safety of all these systems. Checks are also carried out on water temperatures in the house. Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 26 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 4 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 2 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 X 4 X LIFESTYLES Standard No Score 11 X 12 4 13 3 14 X 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 4 4 X 3 X 3 X X 3 X Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 27 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 YA24 Regulation 23 Requirement The registered person must ensure that outstanding repairs to the premises are carried out punctually, so as to ensure a safe environment for the residents. The registered person must ensure that staff records contain evidence that confirms the identity of staff. Timescale for action 30/04/07 2 YA34 17 30/04/07 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 2 3 Refer to Standard YA7 YA23 YA24 Good Practice Recommendations The individual identified during the inspection should be provided with the opportunity to access advocacy services The whistle blowing procedure for staff should include reference to the role of the Commission for Social Care Inspection. A refurbishment plan for the home should be included within a plan covering the next twelve months Lethbridge Road DS0000005309.V315858.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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. 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