CARE HOME ADULTS 18-65
Liberty House 55 Copeley Hill Erdington Birmingham B23 7PH Lead Inspector
Joe OConnor Announced 13 July 2005 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 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 Stationary 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. Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service Liberty House Address 55 Copeley Hill Erdington Birmingham B23 7PH 0121 327 0671 0121 327 0671 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Liberty House Care Homes Ltd Sonia Thompson Care Home 6 Category(ies) of Younger Adults, Learning Disability (6) registration, with number of places Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1 The home is registered to accommodate 6 persons with a learning disability. 2. Service users must be under 65 years of age. Date of last inspection 15 March 2005 Brief Description of the Service: The property is a large Victorian house at the end of a cul-de-sac, off a main road and adjacent to the Aston Expressway in the Erdington area of Birmingham. Public transport is close by and the service has its own vehicle. All community amenities including places of worship are accessible within a short distance of the premises. Liberty House offers accommodation to six service users with a learning disability. Accommodation is provided on both floors. To the front of the premises there are ramps provided. The service is in the process of having some refurbishment to the front of the exterior and driveway. There is an ensuite bedroom on the ground floor. Two bedrooms on the first floor have ensuite facilities and there is a bathroom and WC facilities on the first floor. The ground floor has a WC. There is a spacious lounge with separate dining area. Kitchen facilities are also available and there is a separate laundry area. There is an extensive garden to the rear of the property, which is well laid out and maintained. It includes a barbeque area. The garden slopes upwards and includes ramp and hand rail facilities. Situated to the side of the garden is a large building which the Registered Manager stated she is considering conversion to supported living accommodation.
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This is an overview of what the inspector found during the inspection. This inspection was announced and took place over one day. The Inspector had opportunity to talk to three service users. There were a number of service users who had limited verbal communication and were unable to express their views on life at Liberty House. Two members of staff were spoken with and care practices were observed. A Tour of the premises was undertaken. Service users care plans and risk assessments were inspected. Staff recruitment and training records were also examined and a number of health and safety records were also sampled. The Inspector had opportunity to talk to the Registered Manager. Comments prior to this inspection were received from service users, relatives and various professionals. What the service does well:
Service users live in premises where its external features are similar in design and structure to that of neighbouring properties and its purpose as a care home is not distinguishable. Service users were observed to receive friendly and professional support from care staff. Comments received from service users were generally positive on life in the home. One service users commented, “Staff are helpful and listen to me”. Another stated, “ I am very happy here and I like my bedroom with my on TV and DVD. “ I feel safe because staff always test the fire alarms every week”. Among the comments received from relatives prior to this visit stated, “ I would like to thank staff for all their hard work, it is a lovely home and the staff really care for the residents”. Service users appeared well cared for the climate of the day. Two service users were observed to go out with a member of staff to McDonalds for lunch. Staff showed an awareness and understanding of the service users needs. Most of the staff have completed mandatory training topics and have completed training in the management of medication. Service users have the opportunity through monthly meetings to communicate their wishes and feelings about food provided in the home, as well as recent activities. Service users expressed satisfaction with the meals provided and the manager encourages service users to eat healthily. There is a menu provided and service users have access to a range of nutritious meals and a well stocked range of food is stored in the cupboards refrigerator and freezer. One service user receives a diet that meets her cultural requirements which staff are aware and respect. Service users have access to go into the local community such as colleges, cinema, local pubs and places of interests such as Aston Hall. Service users
Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 6 have access to a vehicle and have been out to visit places such as Stratford Upon Avon and Dudley Zoo. Service users are able to spend time as they please and no rigid rules or routines are present. They are also maintaining contact with their relatives. Service users are encouraged to maintain their independence in areas such as making drinks, cleaning their rooms and managing their laundry. There is a relaxed friendly atmosphere that appears to benefit the service users. They have access to local healthcare professionals such as GP, dentist, optician and chiropodist. Specialist support is available through the local Primary Care Learning Disability Trust. What has improved since the last inspection? What they could do better:
Care plans will require significant modification to ensure they clearly state how the needs of service users are to be met and by whom. They will also need to include information about the service users’ daily routines. One service user was not aware of his care plan and the manager must ensure service users are fully involved in their development and review. The management of medication was found to be good but care must be taken in ensuring that all prescribed creams and ointments have been labelled with the date of opening and that they are disposed of after 28 days to reduce the risk of any contamination. The procedure for the management of medication will require amending to state that any medication errors must be reported to the CSCI and there must be details of the supplying pharmacist. The records of food eaten by service users must be completed on a daily basis
Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 7 as there were gaps on those records sampled during this visit. Service users weight was not being undertaken on a monthly basis. There is a complaints procedure and some amendments were required to ensure it informs service users that they can contact the CSCI at anytime and that service users will receive assurances that no one will be victimised when a complaint is made. However, neither the service nor the CSCI have received any complaints since the last inspection. There is a policy and procedure for the protection for vulnerable adults and discussion was held with the manager to ensure this was in line with the Department of Health Guidelines called No Secrets. Health and satisfactory records were found to be satisfactory but there was an urgent need for the manager to make arrangements for the hard wiring of the premises to be inspected and tested. The risk assessment for the prevention of fire was in need of review. 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. Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 9 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1, 2, 3, 5 Service users receive detailed and clear information about the aims and objectives of the service and about the kind of service they will receive. The current needs of the service users are met. Staff provide positive support and have an understanding of the service users needs. Service users have a written statement of terms that provides a breakdown of their financial contribution to the service. EVIDENCE: There is a statement of purpose and service user guide which sets out clearly information about the service and of the support and care service users will receive. A sample of service users records found that assessments had been completed for each service user covering all aspects of their daily living activities. Two service users provided positive comments about the service. One stated, “ I like living here”. “ My keyworker is very helpful”. Another stated, “We can do what we want and all the staff are good”. A number of comments were received from relatives and professionals who stated. “I would like to thank staff for all their hard work my son has come on really well”. Staff were observed to provide friendly and professional support and demonstrated an awareness of service users needs. Service users appeared well cared for and dressed in clothing that was appropriate to their age. Three service users records sampled found that each one had a statement of terms and conditions.
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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 standard(s) 6, 7, 8, 9 Care plans do not provide a detailed picture of how the needs of service users are to be met and whether they are fully involved in their development and review. Service users are encouraged to make decisions about their lives through service users’ meetings and on a day to day basis with support from staff. Service users have risk assessments in place that ensure staff are aware of how service users are to be escorted and directed. EVIDENCE: Each service user has a care plan that had been reviewed prior to this inspection. Part of the care plans included a tick box checklist with regard to service users needs There was also references to service users likes and dislikes. One example viewed referred to one service user enjoying watching Asian musicals on video. Another referred to another service user enjoying going to his work placement at a garden centre. However, there was no clear information as to how these needs should be met. There was also no reference to service users daily routines. One service user spoken with stated he did not know what a care plan was. Risk assessments were in place and these covered how service users should be supported. One referred for the need of one service user is not left alone when having a shower due to his epilepsy. These were found to have been reviewed.
Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 11 Service users are encouraged to be independent. Two service users stated that they had monthly meetings to talk about meals and future activities and minutes for these were maintained. The service users stated that they could choose what they wanted to eat. One service user stated that the manager looked after monies and was happy with this arrangement. Staff were observed to encourage service users express their preferences such as what they wanted to drink or where they wanted to go. Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 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 standard(s) 11, 12, 13, 15, 16, 17 Service users are encouraged to communicate their needs and develop and maintain their independence. Service users have access to leisure activities and also received organised activities provided by other agencies. Service users maintain positive relationships with each other and staff. Service users routines are not set in full on their individual care plans. Service users are not subjected to any unnecessary restrictions with staff understanding and respecting these. Service users are provided with a nutritious balanced diet but the records of meals consumed are not consistently completed by staff. EVIDENCE: Service users records contained information with regard to their activities during the day. Staff were observed to be encouraging service users to communicate their needs and preferences. One service user was observed doing his laundry and another service user was observed to clear crockery from the tables after having their tea. Another service user was observed to make himself a hot drink. Staff had a good understanding of service users daily routines and these were respected. However, the care plans must provide more information about service users daily routines.
Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 13 An examination of service users found that a number attend day services in the community at college or daycentres provided by the local authority. One service user said he had been to one college for reading and writing. Another service user was coming towards the end of his placement at Nechells Green Garden Centre that is part of the Employment Preparation Team. Service users were able to confirm that they are given the opportunity to go out for a meal, go to the cinema and they had recently participated in outings to Dudley Zoo and Stratford Upon Avon. Some service users have access to their own equipment such as Video, DVD and Hi-Fi systems to pass their own leisure time. Service users also participate in board game activities and a new dartboard was purchased for one service user who enjoys playing darts. Observations at the time of this inspection found that this is very much the service users’ own home with no unnecessary restrictions. Each service user has a key to their bedroom. Service users have access to menus that provided a nutritious balanced diet. Records of meals eaten by service users are maintained, although it was noted that these had not been completed regularly. The refrigerator, freezers and food cupboards were found to be well stocked. Staff knew specific dietary requirements. One service user has a Halal diet, as she is a Muslim. The menu records confirmed when Halal meals had been provided. Service users and staff stated they thought the food was good and that alternatives would be provided if they did not like what was on the menu. The service users were observed to have tea and the atmosphere was found to be relaxed with service users being allowed time to finish their meals. The service user also attended a recent festival known as Mela that was recently held at Cannon Hill Park. Service users records found that service users were able to maintain contact with relatives. Two service users who are brothers are supported to visit their father who lives in a care home. There appeared to be a good relationship between service users and staff. Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 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 standard(s) 18, 19, 20 Service users care is flexible and supports their individual needs, but the care plans do not clearly state how this support is to be given. Service users healthcare is appropriately managed by staff promoting and maintaining good health. Service users’ weight is not recorded monthly as part of the service users’ nutritional well being. Medication management is good with some minor improvements required. EVIDENCE: Care records sampled indicated where service users had completed personal care tasks. However, some of the information on the service users’ care plans did not provide a full picture as to how their personal care was to be delivered. One care plan stated that the service user needed supervision but was not specific in detail. There is a policy statement with regard to gender care. Each service user has a manual handling assessment. One service user has a level access en-suite shower and a shower chair. A grab rail is available in the bath. A sample of service users records found that one service user had epilepsy and that a record of his seizures were being documented. There was a written protocol for the use of rectal diazepam. Service users have access to community healthcare services such as GP, dentist, optician and chiropodist. It was evident that good relationships are maintained with other multidisciplinary services such as community nurse and consultant psychiatrist. There was evidence that service users had medication reviews and one service
Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 15 user had insight into his own problems with anxiety and explained that he had an injection to assist him with this. Two service users stated that they could go to bed and get up when they wanted to. One comment received from a senior community dentist stated that the service had maintained good dental care for the service users and described staff as being helpful and supportive to the service users. Service users are weighed but it was noted that this was not being undertaken on a monthly basis. The management of medication was found to be good although it was noted that a number of prescribed creams and ointments had not been date labelled on the day of opening. Staff have received medication training from the supplying pharmacist, which was a two day course. The medication procedure was found to require some amending to state details of the supplying pharmacist and that any medication errors must be reported to the CSCI. The Medicines Administration Records will need to have individual photographs. Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 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 standard(s) 22, 23 Service users have access to a complaints procedure, which will require some amending. Service users welfare is protected with staff being able to challenge poor practice. Staff received training in the prevention of abuse for vulnerable adults. Work is required to ensure the adult protection policy and procedure is within the spirit of the Department of Health Guidelines No Secrets. EVIDENCE: Neither the service nor the CSCI have received any complaints since the last inspection. A complaints procedure is available and a number of amendments were required to include assurances that no one will be victimised for making a complaints and that the CSCI can be contacted at anytime during the complaint process. Two service users stated that they felt staff and the manager would listen to their concerns. Two staff gave satisfactory responses to questions with regard to protecting service users from abuse and how they would deal with any complaints or had observed poor practice. The majority of staff had completed adult protection training and the manager has a copy of the Multi Agency Guidelines published by Birmingham City Council. However, the adult protection procedure needed some amending to ensure it reflected current practice and that the CSCI was to be informed of any incident or suspicion of abuse. Service users person allowances were not examined during this inspection and will be checked at the next visit. The pre-inspection questionnaire stated that two service users had their own bank accounts. Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 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 standard(s) 24, 25, 26, 27, 28, 29, 30 Service users live in a homely non institutional environment that is maintained and cleaned to an acceptable standard. Service users bedrooms are personalised to reflect their individual lifestyle. Service users have access to a comfortable lounge and dining room that allows freedom of movement. Service users have suitable facilities for bathing including en-suite showers in two bedrooms. Service users are able to use basic adaptations such as grab rails to assist with transferring but also maintain their independence. Staff generally observe infection control practice that maintains service users health and safety. EVIDENCE: The premises was found to be clean, tidy and well maintained. The manager had taken action to address a number of requirements from the previous inspection and a number of bedroom doors had self closing devices fitted to improve service users safety. The manager employs two maintenance persons who were carrying out work to various parts of the premises at the time of this inspection. The manager stated that she was having work done to re-paint the front part of the building. There are also plans to re-build the veranda and have one fitted with UPVC windows. New carpets were to be fitted to the stairs and lounge. New doorframes had been fitted to the dining room.
Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 18 Service users bedrooms were personalised reflecting their individual tastes. One service user’s bedroom had a number of posters of Asian film stars. There was evidence that most of the service users had their own TV, stereo, Video and DVD players. It was noted that not all the bedrooms had two double electrical sockets. There were suitable locks on the bedroom doors that could guarantee service users’ privacy but could be opened by staff in an emergency. Two bedrooms have en-suite shower cubicles while the other bedrooms have wash hand basins. There were appropriate toilet and bathing facilities. There is a toilet on the ground floor that is close to the lounge and dining room. It has a handrail. There is a bathroom on the first floor with a shower cubicle. The bath has a grab rail to assist service users to get in and out. A toilet is also located on the first floor. There is a ramp leading to the front of the premises with a handrail. The manager had replaced some of the tiling since the last inspection and stated that the bathroom would be refurbished. There are disposable towels and liquid soap dispensers in place in the bathroom and toilet facilities. There is a comfortable lounge with TV, DVD and video player along with a karaoke machine. The dining room was found to accommodate all service users and there is also a TV set available. There is a large well maintained garden, which at the time of this inspection the service users seemed to enjoy and it offers them the opportunity to have their own space. There is a separate laundry area with a washing machine and tumble dryer. Appropriate facilities are available for the disposal of clinical waste. Staff were observed to wear protective clothing when working in the kitchen. Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35 The manager offers and provides training to all staff employed to enhance their development but there are some staff that are now due for updated mandatory training. Staffing levels provide service users with a continuity of care. Service users are supported by qualified and competent staff that demonstrates an understanding of the needs of service users in their care. Staff recruitment records are maintained to an acceptable standard that protect the service users’ interests. Staff supervision does not meet the required frequency. EVIDENCE: Two members of staff demonstrated a clear understanding of the needs of service users in their care. Service users routines were known and respected. There was evidence that most of the staff had received training in areas such as first aid, fire safety, manual handling, and food hygiene. However, a number were due for updated training and it was noted that individual staff training records needed to be updated to reflect the training that had been completed during the last six months. Additional training such as adult protection, and epilepsy had also been provided as had medication training. The manager has training matrix to show training provided and required by staff. There are induction procedures for new staff. There are currently three members of staff qualified to NVQ Level 2 with one member of staff who was soon to complete Level 2 qualification. There is one member of staff with NVQ Level 3.
Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 20 Staff recruitment records were found to have all the required information including proof of ID, passport, CRB check, birth certificate, two references, job application form. There was also some evidence training completed with certificates on file. Staff who had completed NVQ 2 & 3 had their certificates on display. Some staff had received supervision but the level of frequency was unsatisfactory and the manager must ensure this occurs every two months. Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 42 Service users live in a home that is run by a qualified and competent manager. There is an open, relaxed and friendly atmosphere that benefits service users and staff. Service users views are being sought through resident meetings and satisfaction surveys but work is still required to develop a wider quality assurance system. Service users’ health and safety is promoted and protected with some improvements required. EVIDENCE: The manager demonstrated her awareness and knowledge of the service users in her care. It was evident that the manager was keen to improve practice and make improvements to the environment for the benefit of the service users. Comments made during the inspection were received positively. She acknowledged there were improvements required with regard to the development of service users care plans. The manager is qualified to NVQ Level 4 in Care and has achieved qualification to the Registered Managers Award. The atmosphere was found to be relaxed and friendly which the service users appear to appreciate. Two service users and staff stated that they could approach the manager if there were any concerns. One staff member
Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 22 commented that she enjoyed her work as it was like being part of a family. The manager has sought the views of service users through satisfaction questionnaires but acknowledged that she was still in the early stages of developing a full quality assurance system. Records with regard to health and safety were found to be satisfactory. There was documented evidence that the fire alarm was being tested on a weekly basis and the emergency lighting every month. The risk assessment for the prevention of fire did not have a date to confirm whether it had been reviewed. It was noted that the hard wiring for the premises was long overdue for reinspection. Portable appliances had been tested prior to this inspection. The most recent fire drill had occurred on 22 February 2005. The accident book was examined and it was good to see there had been no accidents since the last inspection. The kitchen was found to be clean and tidy and a record was being maintained for the refrigerator and freezer. Foodstuffs in the refrigerator were appropriately labelled. Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 x 3 Standard No 22 23
ENVIRONMENT Score 2 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 2 3 3 3 x
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 2 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 2 2 Standard No 31 32 33 34 35 36 Score x 3 3 3 2 2 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Liberty House Score 2 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 2 x 2 2 x v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 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 6 Regulation 15(1)(2) Requirement The Registered Person must ensure that individual care plans have sufficient detail as to how the needs of service users are to be met and by whom including personal care needs. Outstanding Requirement 15 April not met The Registered Person must ensure that service users care plans set out their daily routines and any domestic tasks they are involved in. The Registered Person must ensure that staff complete a daily record of food eaten by service users. Service users weight must be recorded every month. Any reasons why this has not occurred must be documented. The Registered Person must ensure that all creams/ointments are date labelled and disposed of after 28 days in order to reduce the risk of micro-bial contamination. The Registered Person must ensure that the medication procedure is amended to state that medication errors must be Timescale for action 13 September 2005 2. 16 12(2)15(1 ) 13 September 2005 From 13 July 2005 13 August 2005 13 August 2005 3. 17 17(2)4 (13) 12(1)(a) (b) 13(2) 4. 18 5. 20 6. 20 13(2) 13 August 2005 Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 25 7. 22 22(1) 8. 23 13(6) 9. 26 16(2)(c) 10. 35 18(1)(c) 11. 12. 36 39 18(2) 24(1)(a) (b) 13. 42 13(4)23(2 )(b) 14. 42 13(4)23(4 )(v) reported to CSCI. It must also provide details of the supplying pharmacist. The Registered Person must ensure that the complaints procedure is amended to state the following: That service users can contact the CSCI at anytime during the complaint process and that no one will be victimised for making a complaint. The Registered Person must ensure that the adult protection procedure is amended and is within the spirit of the D.OH. Guidelines No Secrets. The Registered Person must ensure that service users bedrooms have two double electric sockets to reduce the use of multi plug extension leads. The Registered Person must ensure that the remaining staff identified have received up to date mandatory training. The Registered Person must ensure that staff receive supervision every two months The Registered Person must develop an effective quality assurance and quality monitoring system, which includes the views of service users and staff that reflects the aims and objectives of the home. Outstanding Requirement. Timescale 15 April 2005 not met. The Registered Person must ensure that arrangements are made for the inspection and testing of the hard wiring for the premises. The current proof of worthiness certificate is now out of date. The Registered Person must ensure that risk assessment for 13 August 2005 13 September 2005 13 September 2005 13 September 2005 13 September 2005 13 September 2005 13 August 2005 13 September
Page 26 Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 fire is reviewed and dated. 2005 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard 24 Good Practice Recommendations It is recommended that the Registered Person forwards to the CSCI a plan of future refurbishment and re-decoration of the premises. Liberty House v230878 e54 s62432 liberty house v230878 130705 stage 4.doc Version 1.30 Page 27 Commission for Social Care Inspection Birmingham & Solihull Local Office 1st Floor, Ladywood House, 45-46 Stephenson Street Birmingham, B2 4UZ National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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