Inspection on 16/11/06 for Liverpool Grove, 26

This inspection was carried out on 16th November 2006.

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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Liverpool Grove, 26 26/07/07

Liverpool Grove, 26 05/01/06

Liverpool Grove, 26 14/07/05

Liverpool Grove, 26 11/01/05

Liverpool Grove, 26 07/09/04

Liverpool Grove, 26 02/10/03

Liverpool Grove, 26 25/04/03

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Liverpool Grove, 26 London SE17 2HJ Lead Inspector Ornella Cavuoto Unannounced Inspection 16th November 2006 10:00 Liverpool Grove, 26 DS0000007089.V318291.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 Liverpool Grove, 26 DS0000007089.V318291.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. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Liverpool Grove, 26 Address London SE17 2HJ 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) 0207 703 1935 0207 703 1935 LINC Robert Agrawal Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 5th January 2006 Brief Description of the Service: Liverpool Road is a Care Home providing personal care and accommodation for four people with a learning disability. The home is run by PLUS (Providence and LINC United Services), a voluntary organisation. The property is actually owned by Hexagon Housing Association and managed by Choice Support. The home is located in Camberwell, close to bus routes, shops, post office, pubs, and most amenities. The home consists of two floors, two bedrooms on the ground floor, one bedroom and an independent flat situated on the first floor that is presently vacant. There is no passenger lift; the ground floor is designed to be wheelchair accessible. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over eight hours. The registered manager was present for the inspection and facilitated the process. In addition two staff members were spoken to. Other inspection methods included observations of the four service users living at the home; inspection of records and a full tour of the premises was undertaken. What the service does well: What has improved since the last inspection? The home has placed a copy of the statement of terms and conditions on service users files. The home is introducing a new format for service users’ care plans to make them more accessible and to be more person centred. The home continues to improve on working with service users to teach them life skills and also service users are involved in doing more structured and leisure activities in and outside the home. Staff have received medication training form a pharmacist and are also being given an opportunity to do further more formal medication training. The home has begun to get plans in place to address service users’ wishes in respect to dying and death. There has been an improvement in the staffing levels within the home to allow for greater flexibility in spending time with service users and supporting them to go out and get involved in activities Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 6 What they could do better: 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. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 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 Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 &5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Prospective service users have the information they need to make an informed choice about where they live. There was some information that the needs of service users have been assessed. A statement of terms and conditions has been issued but this needs to be signed by a representative on behalf of service users living at the home. EVIDENCE: The home has a statement of purpose that includes all the information required by National Minimum Standards and regulation. In respect to the service user guide recommendations have been made at the last two inspections that it should be placed in a format that is made easier for both prospective and current service users to understand. At this inspection it was reported that a more accessible service user guide had been produced by PLUS. This was not available on the day of the inspection but a copy was sent to CSCI shortly following the inspection. The service user guide provides general information on all PLUS services including the registered care homes supported living homes and the community- based services. It is in an accessible format with pictures and is simply written. However, as all but one of the service users living at Liverpool Grove have a dual sensory impairment this is still not an accessible document to meet their individual needs although potentially it may Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 9 be accessible to prospective service users. The registered manager did report at the last inspection that there has been consultation with social workers and the Speech and Language Team (SALT) about how to make the service user guide more accessible to present service users but no alternative approaches could be identified. Therefore this standard is deemed met. All the service users living at the home have been residents since 1994 shortly after care management arrangements had been introduced and needs assessments were carried out by local authorities and before the care standards came into force in 2002. Consequently, evidence that the home had obtained copies of needs assessments was not available apart from two service users where copies of a re-assessment of need had been completed by the placing authority in 2003. At the last inspection it was identified that two of the service users’ personal files looked at did not include evidence of a statement of terms and conditions. At this inspection it was identified that all four service users had a statement of terms and conditions in place issued in 2002 by Choice Support who are responsible for management of the house and these were signed. However, the registered manager reported these had been signed by a housing manager and it is recognised that it would be more appropriate for an advocate or a relative to sign these documents on service users’ behalf (See Requirements). Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7 & 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. A new format for service user plans is in the process of being introduced but the plans have not been regularly reviewed and so do not presently clearly reflect all service users’ personal goals and changing needs. Service users are supported to make decisions about their lives as much as possible. Comprehensive risk assessments have been completed. EVIDENCE: The personal files of all the service users living at the home were looked at. These contained personal profiles that were simply written and had also been written in the first person. Yet, it was specified on the profiles that they had been drawn up using observation and experiences of the key workers, other staff at the home and also relatives in recognition of the service users’ involvement being limited due to their level of disability. The profiles addressed all aspects of personal, social and health care needs including individual preferences and needs around personal care and daily routines such as meal Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 11 times. Specialist requirements in relation to individual communication needs were outlined and there were also some detailed guidelines on interventions used by staff to support individual service users, for example one service user who is wheel chair bound has to have floor exercises and physiotherapy carried out with them on a daily basis. However, the information within the profiles had not been updated for two service users in over a year, June 2005 and for the other two service users the profiles on file had not been updated since April and September 2004 and there was not any evidence that six monthly reviews had been carried out. It was reported by the registered manager that the home is actually in the process of introducing person centred planning and key workers are in the process of transferring and updating information on those service users they are working with into a document that is more person centred and also DVDs are to be used to record information to try to increase its accessibility. The document introduced to be completed for the service users’ profiles was seen and there was evidence from a team meeting held in September where timescales had been arranged for person centred planning meetings to be held and the new profiles on service users to be completed. The minutes of a placement review held in August for one service user also indicated that a person centred planning meeting had been arranged for December 2006. It was reported these timescales have been delayed due to the deputy manager who was taking the lead in this work leaving the home. Although these are positive developments the new profiles need to be completed as soon as possible and regular reviews of the information contained within service user plans/profiles needs to take place at least every six months as specified within the NMS (See Requirements). There was evidence within the personal files that placement reviews with the local authority had taken place in 2005 for all service users and for one service user as mentioned there were minutes available of a placement review held in August 2006. However, there was no evidence available to indicate these had been held for the other three service users living at the home. The registered manager reported that they had been in contact with the local authority to make arrangements for these and written evidence of this was sent to CSCI shortly following the inspection. In relation to supporting service users to take control and make decisions about their own lives all of them have access to an advocate that attends the placement review meetings held annually as are the relatives of those service users where there is contact to ensure decisions are being made that are in their best interests. In addition, the aim of the home introducing person centred planning (PCP) is to ensure service users are provided with as much choice and control in their lives as possible. As mentioned all service users are to have a PCP meeting held. All service users’ had risk assessments in place that covered a range of activities and areas of need and included control measures to reduce risks identified. These had been recently been reviewed. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11,12,13,14,15,16&17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There have been some improvements in supporting service users with their personal development and to learn life skills although this needs to be addressed within service user plans. Service users are provided with opportunities to engage in appropriate activities although accurate records detailing this need to be maintained by the home. Service users take part in the local community and to engage in a range of leisure activities. Service users are able to maintain appropriate personal and family relationships. Routines of the home do respect service users’ rights and to promote independence where possible. Service users do appear to eat a healthy diet although staff are not always recording meals provided. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 13 EVIDENCE: At the last inspection there was limited evidence that service users were being supported with their personal development or being provided with opportunities to learn and use practical life skills. It was reported by the registered manager at that time that this was an area that remained underdeveloped due to difficulties with staffing and the need to offer service users one to one support to be able to fully engage and support them in undertaking tasks. At this inspection it was identified that some improvements had been made in this area. Two of the service users have been involved in cookery sessions of which there was evidence in the personal diaries that are maintained for each individual service user. It was also reported that staff are continuing to work with service users to encourage them to dress themselves and to eat independently which was observed with one of the service users. Furthermore, there are plans to purchase more sensory equipment for individual service users to help stimulate and improve their senses. However, support in these areas need to be more clearly addressed within service user plans/personal profiles so this can be monitored, reviewed and any progress made evaluated (See Requirements) Activities were another area at the last inspection where it was identified that service users have not been provided with sufficient opportunities in or outside the home. As a result, it was required that the home should maintain records of activities that individual service users had been involved in. At this inspection it was reported that service users have been provided with more structured activities for example, two of the service users are taken to a sensory room in Woolwich every other Friday, another service user has been taken swimming whilst one of the service users has been taken to a local leisure centre to use the Jacuzzi. There have been visits to Greenwich Park and finally one of the service users attends trampolining every week and a movement group although this is arranged by physiotherapy. Within the home, service users have been provided with aromatherapy massages carried out by a qualified aroma therapist that visits the home, sensory and music sessions for individual service users, hand and nail care as well as the cookery sessions that has been previously mentioned. There was some evidence that these activities had taken place within the service users’ personal diaries and also on individual monthly activity charts that have been introduced although these had not always been regularly completed and this needs to be addressed (See Requirements). There was some evidence within service users’ personal diaries that they are taken out within the local community to go shopping and also to use the local library to get music CDs. In addition, there is a café that is situated in the church situated opposite the home where service users have gone and as mentioned they have made use of the local leisure centres. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 14 In terms of leisure activities there was evidence within service users’ diaries that service users had been taken out on trips to Thorpe Park, Southend and Brighton. They had also gone on trips to Chessington and Animal Park with PLUS’ Community Services as part of their Summer Programme. In addition, all service users had been on an annual holiday with one service user visiting family in Newcastle, another going to Butlins and two going to Holland for five days in June again with PLUS’ Community Services. Two of the service users also regularly attend the Gateway club where there is a disco held. There was evidence within the service users’ personal profiles and placement reviews that where appropriate service users’ relationships with family and friends are supported and encouraged. As mentioned two of the service users attend the Gateway club where they can meet up with people and it was also reported that the service users attend social occasions at other PLUS homes. The home’s routines do respect service users’ rights and independence. Staff were observed treating service users respectfully and interacting with them. As mentioned individual service users are being supported by staff to increase their level of independence in relation to daily living. Overall service users do have unrestricted access to the home and grounds although due to the level of disability for individual service users this is within a risk management framework. In respect to meals the home no longer has menu plans in order to bring the home in line with the policy used by other PLUS homes where menus are not used. However, the registered manager reported that the old menu plans are still used by staff as a means of getting ideas for meals to cook. Staff are supposed to record the meals eaten by service users in their personal diaries. These were examined and it was found that staff had not always clearly recorded this information. Instead, on occasions they had only specified that breakfast or lunch had been provided or the service user had enjoyed their dinner. In addition, the registered manager reported that staff do not always record all the food provided so the main meal may be noted down but not what they had for dessert or any snacks or drinks. As a result, a new form is to be introduced that was seen. This will require staff to record more precisely meals provided to service users including details of what has been prepared, drinks and snacks and comments made for example, on quantity eaten. It is extremely important that an accurate record of meals is maintained particularly as one of the service users has had difficulty putting on weight so this issue needs to be addressed or the home may need to consider the option of re-introducing menu plans (See Requirements). Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 15 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, 20 &21 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Personal support is provided to service users in a way that meets their individual needs. Service users physical and emotional needs are well met. The home has robust policies and procedures in place for dealing with medication that protect service users. Not all service users have a plan in place that outlines their wishes in respect to ageing and death. EVIDENCE: There was detailed information within all service users’ personal care profiles about their preferences and needs around personal care. As mentioned some of this information is in need of being updated (For details see Standard 6). This is in the process of being carried out although the registered manager did report that the majority of the information still remains relevant. Positively, the specific cultural needs of individual service users have been addressed in respect to supporting them with their personal care in the present information that is in place. The home has a key worker system that ensures consistency of support for service users and the two staff members spoken to had very Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 16 good knowledge about the service users they key work and their individual needs and the support to be provided. Service users were observed as being well dressed and groomed. There was evidence within service users ‘ personal files that their health care needs have been well met. A record of the contact with a range of different health care professionals has been maintained including G.Ps, dentists, district nurses, dieticians, opticians, and podiatrists/chiropodists. Service users have been supported to attend hospital appointments as required. Also as mentioned there are detailed guidelines in respect to interventions put in place by physiotherapy services for staff to follow. In respect to service users emotional needs there was evidence for one service user of contact with a clinical psychologist. There has also been contact with Speech and Language Therapy (SALT), occupational therapy and behavioural support teams in the past. However, only one service user has a referral with the behavioural support team open at present and positively it was noted within the minutes of a placement review for one of the service users that due to the insight of the staff and their effective management of their behaviour that this has led to a decrease in their behaviour that is found to be challenging. The home has a robust medication policy and procedures in place. Subject to a previous requirement all staff have received training on medication from a pharmacist although the registered manager reported that staff are still to attend more formal training courses on medication provided by Lewisham Partnership. Medication Administration Records (MAR) sheets were checked and all found to be accurate apart from a minor error where a diet supplement drink had not been signed for by a staff member. Medication is administered via dossette boxes and these were all accurately labelled meeting a previous requirement. However, it is advised that the homely remedy records that are kept individually for service users must be reviewed and updated if necessary by the G.P (See Recommendations). A funeral plan for only one service user could be identified. The registered manager acknowledged that this is an area that needs to be discussed for the other service users when their annual placement reviews are held (See Recommendations). Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 17 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 &23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Service users have access to independent support to ensure complaints and concerns are addressed on the behalf of service users. Service users are generally protected from abuse although bank staff are not presently provided with training on abuse. EVIDENCE: The home has recently been issued with a new complaints policy that is robust and has also been placed on DVD to increase its accessibility. In addition, a document ‘ Dealing with Complaints Positively- A Guide for Staff’ has been drawn up. As mentioned all service users have an independent advocate allocated to work with them and to ensure any complaints or concerns are addressed on their behalf. The registered manager reported that the new complaints policy is yet to be sent to the advocate who has a copy of the old policy. It is advised this is done as soon as possible (See Recommendations). A complaints log is maintained by the home but there have been no complaints recorded since the last inspection. The home’s adult protection policy and procedure was in the process of being updated by PLUS and so was not available for inspection. However, the home had a copy of the London Borough of Southwark’s Interagency Guidelines on Adult Protection for staffs’ information. It is the policy of the agency that all permanent staff as part of their probationary procedure have to complete the Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 18 Learning Disability Award Framework (LDAF) Units 1-4 which includes receiving training on adult protection. Staff members spoken to had good knowledge of adult abuse and procedures to be followed if abuse was suspected or identified. However, it was identified during the inspection that bank staff members do not receive training on adult abuse although the registered manager reported that as part of an in –house induction programme they would receive information about the policy and procedures and there was evidence this has been completed. However, it is important all staff receive training in this area and this needs to be addressed (See Requirements). The registered manager is the appointee for all the service users in terms of the management of their finances. There were robust procedures in place with accurate records in place and receipts kept for all transactions. The registered manager aims to carry out audits of the finances fortnightly. The issue of the local authority taking the financial records of one of the service users back in 2004 to be externally audited was not addressed at this inspection. At the last inspection it was reported that the home had still not received feedback about this issue. This will be discussed at the next inspection. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 19 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): 24,26, 27,28 &30 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Overall, the home is well maintained, homely and comfortable. Service users’ bedrooms suit their individual needs and toilets and bathrooms provide sufficient privacy and meet their individual needs. Communal areas are spacious and complement service users’ individual rooms. The home is clean and hygienic. EVIDENCE: The home provides a safe, homely and well-maintained environment. The ground floor is wheel chair accessible and furnishings are of a good quality and domestic in character. Subject to a previous requirement the kitchen worktop was replaced where it was burnt but this has occurred again and so needs to be replaced or part of it replaced again (See Requirements). All service users have their own individual rooms that are a good size and are furnished to required standards. Two of the bedrooms have en –suite bathrooms, one on the ground floor and one upstairs although this is shared Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 20 with the other service user whose bedroom is upstairs. All the bedrooms have been nicely decorated and all of them have been personalised to reflect their individual needs, interests and culture. Also, upstairs there is a self- contained flat. This is presently unoccupied although it was reported that the home has received a referral for someone to move in. This is presently being considered. There are sufficient bathrooms and toilets to meet the needs of the service users. Subject to a previous requirement the registered manager reported that attempts have been made to place hand washing facilities and hand towels in the down stairs bathroom but these are persistently destroyed and removed by one of the service users who uses this toilet and does not like anything on the walls or to be in the toilet. As a result this will not be restated as a requirement although it is advised that this is addressed in a risk assessment in terms of the issues relating to infection control (See Recommendations). The home has accessible communal areas with a large spacious lounge/dining area on the ground floor that has patio doors that lead out to a good- sized garden that is very attractive and well maintained. The kitchen is also spacious and has a small table where service users can sit and eat. The home was clean and hygienic on the day of the inspection. Subject to a previous requirement hand washing facilities have now been placed in the laundry room. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 21 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): 32,33,34 &35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are being supported by the home to achieve relevant qualifications to ensure they are able to meet the needs of service users effectively. Staffing levels have increased for the team to be able to meet the needs of service users more effectively but the registered manager’s role needs to be surplus to the rota There was insufficient information available to fully assess whether service users are protected by the home’s recruitment practices. Staff are given sufficient opportunities for training to ensure that service users’ individual and joint needs can be met. EVIDENCE: At present four of the eight staff working at the home are presently undertaking National Vocational Qualifications (NVQ) with two doing NVQ Level 2 and two doing NVQ Level 3. The registered manager also reported that one of the bank staff that is working on the rota on a regular basis is doing a NVQ Level 4. As mentioned all permanent staff are required to complete the Learning Disability Award Framework (LDAF) Units 1-4 in their probationary period. Given that 50 of the staff team are working towards a relevant Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 22 qualification in addition to having completed part of the LDAF this standard is deemed met. Subject to a previous requirement that the staffing levels of the home should be reviewed to ensure that there were adequate staff to allow for service users to be supported with undertaking activities in and outside the home and also to be able to carry out skills teaching sessions with service users, this has been met. The registered manager reported and the rota that was seen reflected that there are more staff available with three staff working in the morning and this is increased to four if there are activities planned or appointments to be arranged. Two staff sometimes three work in the afternoon/evening and one staff member does a sleep –in. However, the rota also indicated that the registered manager is included on the rota to do a sleep- in shift once weekly. They reported that they found it useful to do a shift although it was also evident in discussing the matter that this has interfered with the registered manager being able to carry out all their duties and responsibilities in relation to the management of the home particularly since the deputy manager left who it was reported is not to be replaced. It is advised this is reviewed with the manager’s role being made surplus to the rota with the occasional sleep in being undertaken if the manager chooses but not on a regular basis (See Recommendations). The home does not keep staff recruitment records at the home these are held at head office. However, CSCI gave PLUS some forms where all the necessary information on staff required for inspection could be recorded and maintained within the home. These were inspected but had not been fully completed so this standard could not be fully assessed. This needs to be addressed (See Requirements). All new staff have to undergo a five day induction held at head office in which they complete all mandatory training including manual handling, first aid, fire safety, health & safety and food hygiene. This is updated as required. Also, as part of the induction staff are given an introduction to working with individuals with learning disabilities and then as mentioned they have to complete the LDAF units 1-4 within their probationary period before being assessed to go on to do either a NVQ Level 2 or 3. There was evidence an annual appraisal had been completed with all staff and a personal development plan put in place in which individual staffs’ training needs had been identified for the year. Training courses booked for staff and those that have been completed included medication, epilepsy, cerebral palsy, skills teaching, capacity to consent, person centred planning amongst others and were clearly organised to ensure that the individual and collective needs of service users can be effectively met. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 23 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 &42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Overall service users benefit from a home that is well run. Although the home does have some systems in place to The health, safety and welfare of service users are well promoted and protected. EVIDENCE: The present manager was acting manager before taking up the post permanently in August 2005. He has completed the registration process since the last inspection and has a NVQ Level 4 in care and has also done the Registered Managers Award (RMA). In addition he has a BA degree in Sociology and has done a Certificate in Management Studies (CMS). Generally, the home is well managed and well run. The registered manager is in the process of introducing a lot of new documents and systems to increase the efficiency of the home and ensure the needs of service users are met more Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 24 effectively. However, as mentioned the decision to be included in the rota needs to be reviewed (For details see Standard 33). The home does have some quality systems in place to ensure standards are met. A self audit document was drawn up by the deputy manager that addresses health and safety, training, medication, finances, policies, service user files, staff files amongst others although this is yet to be implemented. The home has to complete a quarterly monitoring report for Commissioners at London Borough of Southwark that provides updates on service users’ progress and outlines goals to be achieved with service users, generally for the home and with staff. A copy of this is also sent to CSCI. As mentioned the registered manager aims to carry out audits of service users’ finances fortnightly. There was evidence that monthly provider visits have been completed although copies of these have not been sent to CSCI as required. Furthermore, a formal quality assurance system, (PQASSO) is being piloted by PLUS. However, customer satisfaction surveys are not presently being carried out annually with service users, relatives, advocates and other professionals with links with the home as part of self-monitoring. The results of these surveys should be included in a report and copies made available to service users, relatives and also to CSCI (See Requirements). The home has robust health and safety policies and procedures in place. As mentioned staff have all areas of mandatory training regularly updated. Incidents reports have been completed and sent to CSCI as required. In terms of fire maintenance there was evidence that alarm call points have been tested weekly and fire drills have been carried out regularly. Maintenance checks of other fire equipment have been completed and the home had an inspection carried out by the LFPEA and have fitted magnetic door holding devices as recommended in the report. An up to date fire risk assessment was sent to CSCI shortly following the inspection. Risk assessments had been completed covering aspects of health and safety of the building. Subject to a previous requirement the cupboard in which hazardous substances were kept was locked. There was an up to date gas safety maintenance certificate in place as well as one for the hoist equipment used, a Portable Appliance Testing (PAT) certificate and a certificate for electrical wiring for the home. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 25 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 3 2 3 3 X 4 X 5 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 2 ENVIRONMENT Standard No Score 24 2 25 X 26 3 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 2 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 2 12 2 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 2 3 X 2 X X 3 X Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? Yes 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 YA5 Regulation 5(1) (b) Requirement Timescale for action 31/03/07 2. YA6 15 3. YA11 12 (1) & (2) 4. YA12 16 (2) (n) The registered person must ensure that all service users are issued with a written contract outlining the terms and conditions of their stay and that this is signed by the service user a relative or a representative where appropriate. (Previous timescale of 31/07/06 partially met) The registered person must 31/05/07 ensure that all service users have a care plan in place that is reviewed at least every six months as specified within the NMS to ensure service users’ personal goals and changing needs are reflected. The registered person must 31/05/07 ensure that service users are provided with opportunities to learn and develop life skills and this is monitored and recorded within the service user/care plan. (Previous timescale of 31/07/06 partially met) The registered person must 31/05/07 ensure that all staff consistently record the activities that service users partake in using the DS0000007089.V318291.R01.S.doc Version 5.2 Liverpool Grove, 26 Page 27 activity charts provided. 5. YA17 16 (2) (i) The registered person must ensure that all staff maintain an accurate record of all meals provided to service users. The registered provider needs to ensure that all staff including bank staff receive training in adult abuse. The registered person must ensure that the kitchen worktop that is damaged is replaced. The registered person must ensure that an effective quality assurance system is in place based on seeking the views and reporting back findings to service users, their families and other stakeholders. Also, to ensure as part of quality assurance that monthly unannounced visits are carried out by the responsible individual and copies of the report sent to the commission. 31/05/07 6 YA23 13(6) 31/08/07 7. 8. YA24 YA39 23 (2) (b) & (c) 24&26 31/05/07 31/08/07 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. Refer to Standard YA20 Good Practice Recommendations The registered person should try to ensure that the homely remedies information for each service user is updated by the GP. The registered person needs to try to ensure that clear plans showing service users wishes regarding death and dying are put in place. Also the home needs to consider whether service users need support to make a will The registered person should try to ensure that a copy of the new complaints policy is sent to the advocate of all the service users as soon as possible. The registered person should try to ensure that a risk DS0000007089.V318291.R01.S.doc Version 5.2 Page 28 YA21 3. 4. YA22 YA27 Liverpool Grove, 26 5. YA33 assessment is drawn up regarding the service user removing all hand washing facilities in the down stairs toilet and what alternative measures need to be taken with regards following infection control procedures. The registered person needs to try to ensure that their role is kept surplus to the rota to enable them to focus on their responsibilities in respect to the day-to-day management of the home. Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH 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. Extracts may not be used or reproduced without the express permission of CSCI Liverpool Grove, 26 DS0000007089.V318291.R01.S.doc Version 5.2 Page 30 - 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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