Inspection on 05/01/06 for Liverpool Grove, 26

This inspection was carried out on 5th January 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 12 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 16/11/06

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 5th January 2006 10:00 Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 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 LINC Ms Teresa Lipski Care Home 5 Category(ies) of Learning disability (5) registration, with number of places Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th July 2005 Brief Description of the Service: Liverpool Grove is a Care Home providing personal care and accommodation for four people with a learning disability. The home was managed by LINC, a voluntary organisation who have recently merged with another organisation to become Providence and LINC United Services (PLUS). 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, there are two bedrooms and an independent flat on the first floor. There is no passenger lift but the ground floor is designed to be wheelchair accessible. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection that was carried out over six hours. The four service users presently living at the home were seen and two staff that have been working at the home since August were spoken to. The registered manager was not available on the day of the inspection but was spoken to shortly after the inspection took place. What the service does well: What has improved since the last inspection? What they could do better: The home needs to look into ways of trying to make the format of the service user guide and complaints policy into one that would be more easily understood by service users. All service users need to be issued a contract outlining the terms and conditions of their stay. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 6 The home needs to develop leisure activities both in and outside of the home and also arrange more skills teaching sessions for service users to ensure they have opportunities to develop and learn new skills. The home needs to ensure that where alternatives are offered from what is specified on the menu that this be recorded for all service users. The home must ensure that all staff receive medication training from a pharmacist prior to being allowed to administer medication. The home needs to review staffing levels to enable more time to be dedicated to service users to help improve their quality of life in terms of staff being able to do more structured activities with service users. The present manager must ensure that an application for registration as the home manager is completed and submitted to CSCI. The home needs to ensure that all aspects of health and safety policy and procedures are followed. 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. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1&5 Although, the home has a statement of purpose and service user guide currently in place it is not currently of use directly to service users. Prospective service users know that the home will meet their needs and aspirations. Not all service users have been issued with a written contract. EVIDENCE: At the last inspection a recommendation was made that the home should continue to look at ways to make the service user guide and complaints procedure easier to understand for service users so they need less staff support. It was reported by the present manager of the home that this has been looked at and discussed at length with social workers and also with the Speech and Language Team. However, neither could advise how to make the Service User Guide more accessible to the present service users of whom all but one have a dual sensory impairment. Despite this, it is still considered important that the service user guide is continued to be looked at to make the format more accessible for present service users and also for prospective service users. Therefore, this is restated as a recommendation in this report. Service user files for all the service users presently living at the home were inspected. Two service users did not have written contracts outlining the terms and conditions of their stay. These would need to be signed by a relative or a representative, as the service users are unable to sign. Subject to a requirement. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 9 Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 10 Overall service users confidentiality is being met although where correspondence includes information about two service users this needs to be separated before being included in service user files. EVIDENCE: The home has a robust confidentiality policy and service users files are kept in a locked cabinet within the office that is also lockable. In addition, staff spoken to were clear about their responsibilities in relation to maintaining service users confidentiality. However, it was noted on service users files that correspondence had been sent which included information on two of the service users living at the home and a copy had been placed on each of their files. Potentially, this could breach service users confidentiality. Consequently, the home should request in future that all correspondence and reports from agencies are individualised or that the information is separated and blanked out before being included in service users files. In addition, team minutes that include information on service users should be placed in a file rather than a copy pinned on the notice board in the staff office. Subject to recommendations. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11,14,15 &17 Although, the home is taking measures to provide service users with opportunities for personal development the staff are limited in the time they have available to carry out skills teaching sessions with service users. Service users need to be given more opportunities to engage in leisure activities in and outside the home. Service users are supported to have appropriate relationships. Service users are generally offered a healthy diet but where alternatives are offered these need to be recorded for all service users. EVIDENCE: There was evidence from service user plans that two of the service users have been given opportunities to learn and use practical life skills such as being supported to do their own laundry, helping to do the monthly shop, helping to prepare meals, tidy and clean their rooms amongst others. In addition, there was evidence that service users are offered specialist interventions and opportunities by trained staff such as occupational therapists and the speech and language team to maximise their individual potential in respect to communication, emotional, social and independent life skills. However, it was noted from service user files that certain service users do not receive any skills Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 12 teaching. It was reported by the manager that this is an area that has remained underdeveloped due to difficulties with staffing and the need to offer the service users one to one support to be able to fully engage and support them to undertake tasks and activities of daily living. This is an ongoing issue that the manager has been addressing with the organisation to try to find ways to supplement the staff team in order to allow more time to be dedicated to service users in this area. In addition, although the manager has experience of skills teaching the present staff team require training to help them support service users more effectively. To address this the manager has completed training sessions within team meetings and has also arranged for two support workers to attend a skills teaching course which is to be held shortly. Subject to a requirement. In respect to the provision of leisure activities for service users it was reported that this is also an area that remains under developed and staffing levels make it difficult to support service users with undertaking leisure activities particularly outside the home. Some of service users do attend the Gateway club where they do various activities such as music and dance sessions. One service user attends a sensory room weekly and another service user attends a trampoline and movement group but the physiotherapy team facilitates this. There was also evidence that activities such as horse riding and art and sculpture are being looked into for certain service users to enable them to pursue individual hobbies and interests and the staff support service users with sensory sessions within the home and do take service users out for walks and to attend the local shops All service users have an annual holiday arranged. However, overall it was evident that at present the level of activities being offered by the home is limited. The manager reported that weekly activity schedules are now being put in place that presently focus on developing the leisure activities carried out with service users within the home rather than outside. However, these were not available on the day of the inspection. Also, there was little evidence of the service users being engaged in any activities the day the inspection was carried out. Subject to a requirement. There was evidence from service user plans and it was also reported by the manager that where appropriate service users’ relationships with family and friends are supported and encouraged. Visits between homes are also arranged to encourage social contact with others. Subject to a previous requirement that one of the service users discussed at the last inspection receives suitable support to ensure they can decide whether to make contact with their family, this has been met. The manager related that after long discussions with the social worker the appropriateness of whether to pursue contact was questioned and a decision was taken not to pursue the matter further. The menu was examined which is a 4 -week rolling menu and it was evident that service users are offered a healthy balanced diet. Two of the service users have particular issues with food and eating and food diaries are kept to monitor their food intake and where an alternative is given this is recorded in a Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 13 food diary and periodically looked at by a dietician. However, where alternatives are offered to the other service users these are not being recorded making it difficult to identify if the menu is satisfying their needs. Subject to a requirement. Subject to a previous requirement that service users are supported to make informed choices regarding food providing appropriate planning for them to experience different foods appropriate to their needs at home and in the community this has been met. The menu does offer a range of different foods to service users and it was reported by the manager that service users have been taken out to eat although this has not proved particularly successful as service users have rarely eaten when taken to eat out. A previous recommendation that the home refer the service user an OT or other appropriate professional to advise regarding adaptations or support that would make the service user more this has been met with an eating assessment having been carried service user by an occupational therapist. discussed to any further independent out with the Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21 Service users’ physical and emotional health needs are well met. Service users are protected by the home’s policies and procedures for dealing with medication. There needs to be further consultation with service users or their relatives/representatives about their wishes around illness and death. EVIDENCE: Standard 18 was considered to be met at the last inspection but a recommendation was stated that information about the communication needs of service users should not be displayed and instead used in supervision of staff, staff meetings, handover, key work sessions and other meetings where all staff are supported appropriate to their needs, information is effectively shared and service users are supported according to their needs. Although, it was evident that information regarding service users communication needs was no longer on display other aspects of the recommendation were not able to be fully inspected and will be carried over to the next inspection. Therefore, this will be partially restated as a recommendation in this report. It was clearly evident form service user plans that were inspected that service users physical and emotional health needs are comprehensively being met. There is close liaison with a range of healthcare professionals including occupational therapists, physiotherapists, mental health teams, psychologists, Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 15 speech and language teams, opticians and dentists. The staff also use activities and aromatherapy to help service users use and improve their sensory abilities. The home has a robust medication policy in place. None of the present service users administer their own medication. A sample of medication administration record sheets (MARS) was inspected and was found to be accurate. All staff receive in house training prior to being allowed to administer medication although not all staff have received training from a pharmacist. It was reported by the manager that the pharmacist is to attend the next team meeting within the following week that the inspection was being held. However, a new requirement is to be stated that all staff must receive training from a pharmacist prior to be allowed to administer medication to service users. In addition, a previous requirement that the manager must consult with the Primary Care Trust regarding the labelling of dossette boxes to resolve the contradictory advice form a pharmacist and the supplying chemist, clarification has still not been sought on this issue. Therefore, this is to be restated as a requirement in this report. With regards to service users their relatives or representatives where appropriate being consulted about their wishes around death and dying although there was evidence within reviews that have been held with some of the service users that this has been discussed there were no clear plans in place to address these issues. Furthermore, a previous recommendation that the home needs to consider whether service users need support to make a will this still has not been addressed. Therefore, a recommendation is to be restated in this report. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 16 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 23 Service users are protected from abuse, neglect and self-harm. EVIDENCE: The home has robust policies and procedures on adult protection and staff spoken to stated they have received training in adult protection although this could not be confirmed by inspection of staff training records as the manager was not present at the inspection to give access to this information. However, staff were very aware about signs of adult abuse and what action to take if they suspected abuse was occurring in the home. In respect to service user finances this could not be fully inspected, as the manager was not present to give access to records. However, it was noted that there was an ongoing issue in relation to concerns raised about the management of the personal finances of one service user, which resulted in Social Services taking financial records to be externally audited in August 2004. This was discussed with the manager who stated that the home is still to be given feedback about the audit. This will be looked at in more detail at the next inspection. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25,26,27,28 &30. In general service users live in a homely comfortable and safe environment but minor repairs need to be addressed. Service users bedrooms suit their needs and lifestyles. Service users bedrooms promote their independence. In general service users toilets and bathrooms provide sufficient privacy and meet their individual needs although there were no hand washing facilities in one of the toilets. Shared spaces complement and supplement service users’ individual rooms. The home is clean and hygienic but there were no adequate hand washing facilities in the laundry room. EVIDENCE: The home is spacious, homely, suited to its stated purpose and generally well maintained. The ground floor is wheel chair accessible and furnishings are of good quality and domestic in character. Subject to a previous requirement that one of the service users is supported to obtain suitable window covering following guidance from the occupational therapist, this has been met. However, the requirement that the kitchen worktop be replaced has not been met and will be restated in this report. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 18 All service users have their own individual bedrooms that are a good size and are furnished to required standards. Two of the bedrooms have en-suite bathrooms. Each bedroom is well decorated and have been personalised to reflect their individual interests, needs and culture. There are sufficient bathrooms and toilets to meet service users needs and provide sufficient privacy. However, in the downstairs toilet the mirror was missing and there were no hand washing facilities. It was reported that despite efforts to replace the soap dispenser and hand towels one of the service users repeatedly tears them down, as they do not like anything being on the walls. This is also the case with the mirror. However, the home needs to find a way of maintaining hand-washing facilities in the toilet as part of infection control. Therefore this is to be stated as a requirement in this report. The home has accessible communal spaces with a large spacious lounge/dining area on the ground floor that has patio doors that lead out into a good-sized garden that is attractive and very well maintained. The kitchen is of spacious and also has a small table where service users can sit and eat. The home was clean, hygienic and free from offensive odours on the day of the inspection. The home has adequate laundry facilities although it was noted that there were no hand washing facilities. The home had adequate policy and procedures for control of infection. Subject to a requirement. . Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 19 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33&35 Service users benefit form clarity of staff roles and responsibilities. Although, it is evident that service users are supported by a competent staff team they would clearly benefit from higher levels of staffing to allow for more individual work to be carried out with them. Service users individual and joint needs are met by appropriately trained staff. EVIDENCE: The staff spoken to on the day of the inspection were very knowledgeable and aware about service users needs particularly those service users that they key work and about their roles and responsibilities in respect to supporting service users. Although, it is evident that service users are supported by a competent staff team as has been previously discussed it is clear that service users would benefit from higher staffing levels at times to enable service users to benefit from having more time spent with them doing skills teaching and also to be able to partake in leisure activities in and outside the home. This is an issue that the present manager has been advocating for and one suggestion has been to look at the recruitment of volunteers. The home presently has a full complement of staff and uses regular bank staff to cover illness and annual leave and to supplement staff cover as required. Subject to a requirement. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 20 Standard 34 could not be inspected as all recruitment records are held at the organisations head office and so will be checked at a later date. The staff spoken to that both started in August reported that they are both working towards achieving the Learning Disability Awards Framework (LDAF). One commented “We learning as we are work and have been given a lot of training”. They stated that as part of their induction they did mandatory training. There was evidence of a list on the notice board to monitor when staff require their mandatory training updated. The manager reported that training is accessed via Lewisham Partnership and all staff are supported to do the LDAF. Training records could not be inspected as the manager was not present for the inspection. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 21 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37,38,39 &42 Service users benefit from a well run home but the manager needs to submit an application to become registered under the Care Standards Act 2000. Also, the manager must ensure that all certificates and licences issued are fully displayed within the home. Service users benefit from the ethos, leadership and management of the home. There home does not have adequate systems in place to ensure effective selfmonitoring. The health and safety and welfare of service users are not being completely promoted and protected. EVIDENCE: The present manager has been in post for several months and has valuable experience working with service users with learning disabilities. He was the deputy manager at Liverpool Grove before taking up the position of manager. He has completed the NVQ Level 4 qualification and Registered Managers Award and also has a Certificate in Management Studies. However, he is yet to submit an application to become the registered manager as required under the Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 22 Care Standards Act 2000 and this needs to be completed as soon as possible. Subject to a requirement. In addition, although the home is well run it was noted on the day of the inspection that the home’s registration’s certificate was only partially displayed. This is a breach of the Care Standards Act and needs to be addressed. Subject to a requirement. There was evidence to indicate that the present manager has developed a positive and inclusive ethos within the home with feedback from staff confirming that the manager is very approachable, supportive and does encourage an exchange of ideas and contributions from staff. Subject to a previous requirement that the home must ensure it has an effective quality assurance and monitoring systems in place, based on seeking the views of service users and /or their advocates, this has still not been addressed and therefore is to be restated as a requirement in this report. Although, the home did have health and safety policies and procedures in place and infection control and also an environment/building health and safety risk assessment has been completed. However, in a tour of the building the cupboard in which hazardous substances are kept was found to be unlocked potentially placing service users at risk. The fire safety book was inspected that had been kept up to date with call points being tested and there was evidence that maintenance of fire safety equipment has been carried out. However, evidence that water temperatures are tested regularly was not accessible. Also, in checking maintenance certificates an up to date certificate for the bathroom hoist could not be identified. Subject to requirements. Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 3 2 X 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 X 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 3 27 2 28 3 29 X 30 2 STAFFING Standard No Score 31 3 32 X 33 2 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X 3 LIFESTYLES Standard No Score 11 2 12 X 13 X 14 2 15 3 16 X 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X 3 2 2 2 3 3 X X 2 X Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 24 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5(1) (b) Requirement 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. The registered person must ensure that service users are provided with opportunities to learn and develop life skills and this is monitored and recorded within the service user plan. The registered person must ensure that service users are provided with opportunities to partake in a range of leisure activities in and outside of the home and these are monitored and recorded. The registered person must ensure that where alternative meals are offered to service users apart from what is on the menu that this is recorded. The registered person must consult with the Primary Care trust regarding the labelling of dossette boxes to resolve the DS0000007089.V275839.R01.S.doc Timescale for action 31/07/06 2. YA11 12 (1) & (2) 31/07/06 3. YA14 16 (2) (n) 31/07/06 4. YA17 16 (2) (i) 31/07/06 5. YA20 13 (2) 31/03/06 Liverpool Grove, 26 Version 5.1 Page 25 6. YA20 13(2)&18 (1)(c)(i) 7. YA24 23 (2) (b) & (c) 13 (3) 8. YA30 9. YA33 18 (1) (a) 10. YA37 8(1)&(2) &9(1)&(2) 11. YA37 CSA 28. 12. YA42 13 (4) & 23 (4) contradictory advice from a pharmacist and the supplying chemist. (Previous timescale of 31/10/05 not met) The registered person must ensure that all staff receive medication training from a qualified pharmacist prior to being allowed to administer medication. The registered person must ensure that the kitchen worktop is replaced. (Timescale of 31/10/05 not met) The registered person must ensure that there are handwashing facilities placed in the downstairs toilet and also in the laundry room to facilitate infection control. The registered provider must ensure that staffing levels are reviewed to ensure that there are adequate staff available to enable service users are given opportunities for structured activities such as skills teaching sessions and leisure activities I and outside of the home. The registered provider must ensure that the present manager of the home submits an application to be registered as required under the Care Standards Act 2000. The registered manager must ensure that all required licences and certificates are displayed within the home at all times. The registered manager ensure that staff adhere to all health and safety procedures including keeping all hazardous substances in a locked cupboard and that all equipment is maintained regularly. 30/04/06 30/04/06 31/07/06 31/07/06 31/03/06 31/03/06 31/07/06 Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 26 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 YA1 Good Practice Recommendations The home should continue to look at ways to make the Service User Guide and complaints procedure easier to understand for service users so they need less staff support. The registered person should consider informing agencies that when sending correspondence about service users this is individualised. Also, to keep team meeting minutes in a folder rather than pinned on staff notice board. Information on service users communication needs be discussed in staff supervision, staff meetings, handover, key work sessions and other meetings where all staff are supported appropriate to their needs, information is effectively shared and service users supported according to their needs. The registered person needs to put in place clear plans showing service users wishes regarding death and dying. Also the home needs to consider whether service users need support to make a will. 2. YA10 3. YA18 4. YA21 Liverpool Grove, 26 DS0000007089.V275839.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection SE London Area Office Ground Floor 46 Loman Street Southwark SE1 0EH National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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