Inspection on 21/05/07 for Liverpool Road (23)

This inspection was carried out on 21st May 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Liverpool Road (23) 09/03/07

Liverpool Road (23) 03/02/06

Liverpool Road (23) 28/10/05

Liverpool Road (23) 23/03/05

Liverpool Road (23) 23/06/04

Similar services:

Henry Nihill House

Birchwood

The Infirmary

Orchard House Nursing Home

St Josephs Rest Home

Red Court Nursing Home

Spinney (The)

Queen Elizabeth House

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

CARE HOMES FOR OLDER PEOPLE Liverpool Road (23) 23 Liverpool Road Thornton Heath Croydon Surrey CR7 7RE Lead Inspector Jon Fry Key Unannounced Inspection 21st May 2007 10:40a X10015.doc Version 1.40 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 Road (23) DS0000028100.V340372.R02.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 Older People. 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 Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Liverpool Road (23) Address 23 Liverpool Road Thornton Heath Croydon Surrey CR7 7RE 020 8653 5280 T/F 020 8653 5280 no email 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) Mrs Daphne Mahoney Mrs Daphne Mahoney Care Home 3 Category(ies) of Old age, not falling within any other category registration, with number (3) of places Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th March 2007 Brief Description of the Service: Beatitudes, 23 Liverpool Road, is located in a quiet residential area of Thornton Heath. The home is near to local shops and well placed for transport links. The service provides care and accommodation for up to three older people and operates very much as a small family home. People living there have a single bedroom and can access a lounge, dining area and garden. Fees are £350 to £400 per week. Additional charges are made for the use of escorts and the disposal of clinical waste. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out by one inspector who spent two and a half hours at the service. Only one person was actually resident at the home at the time of this inspection visit. This person did not want to speak with the inspector. A number of records were examined and discussions took place with the owner who also lives at and manages the home. An Annual Quality Assurance Assessment (AQAA) was completed by the owner before the inspection took place. What the service does well: What has improved since the last inspection? What they could do better: Care plans could be improved by making sure that social care needs are fully addressed. Improved access to continence equipment and advice should be sought via the GP. Training around Safeguarding Adults, activities, dementia care and person centred care should be looked at in order to continue to develop the service. A certificate needs to be obtained to show that an annual gas safety check has been completed. A rusty bathroom handrail needs replacing. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 6 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 Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3. People who use the service experience adequate quality outcomes in this area. Adequate information is provided to people about the home. The needs of people living there should be more regularly reviewed and their assessments updated. EVIDENCE: A guide to the home is available which contains satisfactory information about the service it provides. This guide includes the complaints procedure for the service. Assessments looked at for one person living there were in need of updating. The owner said that this person required a full re-assessment from the placing Local Authority as their needs had changed in the last year. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. People who use the service experience good quality outcomes in this area. Care plans adequately detail the support needs of people using the service. They could be improved to look at how social needs are being met. The health needs of individuals are met and medication is well managed. EVIDENCE: We looked at the care plan for one person. This was kept up to date and reviewed regularly. Areas of support covered included mobility, nutrition, and physical health. The plan could be improved by looking at the social needs of the person and how these are to be met. This is particularly as individual needs increase and access to community and leisure facilities becomes more difficult. Records seen showed that individual healthcare needs are fully addressed. This included support to see the GP, optician and to attend hospital Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 10 appointments as required. We saw that good records are kept of the food and fluid intake of individuals when this is required for health monitoring. We have recommended that the owner gets a referral from the GP to see a continence advisor. This may help to obtain newer equipment and supplies for the benefit of those living at the service. Medication is managed well. We saw that items of medication are securely stored and given to people at the right time with full records kept. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. People who use the service experience adequate quality outcomes in this area. People living at the home are provided with opportunities for recreational and social activities. Care plans need improvement to better address social needs. A varied menu is provided to individuals although better records need to kept of the food provided. EVIDENCE: The owner talked about the increasing health needs of people living at the home. This was affecting their ability to access day centres and activities outside the home. A record of activities is kept by the service and we saw that these were being provided to individuals within the home environment. Activities provided include quizzes, music and television. As stated previously, care plans need to be improved to look specifically at the social needs of individuals and be reviewed monthly. It is recommended that the owner looks at accessing training around activities and person centred care to help develop the service. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 12 There is a revolving menu in place but the owner said that meal choices tend to be discussed informally and chosen on a daily basis with the people living at the home. The service needs to keep better records of the food provided if different from the menu. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. People who use the service experience good quality outcomes in this area. Arrangements for complaints and safeguarding from abuse are generally well managed. EVIDENCE: We saw that there are satisfactory procedures for responding to allegations of abuse and for managing any complaints made about the service provided. The complaints procedure is part of the guide made available to people living there. The owner has obtained a copy of the new Local Authority Safeguarding Adults procedure. It is strongly recommended that the owner and staff attend training around this new procedure as it becomes available. One new member of staff requires full training in Safeguarding Adults. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 24 and 26. People who use the service experience adequate quality outcomes in this area. The environment is clean, comfortable and homely. The home is maintained, decorated and furnished to an adequate standard. EVIDENCE: This is a small home and is furnished and decorated in a comfortable homely way. The home is kept clean and generally adequately maintained. The carpet in one bedroom has been replaced as requested at the March 2007 inspection. Bedrooms provide adequate accommodation for individuals. As stated previously, the owner should try to get further advice and equipment from the local continence service via the GP. Equipment in use was seen to be rather worn and in need of replacement. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 15 The kitchen is still functional but looks in need of some renovation. A rusty handrail in the first floor bathroom needs replacing. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. People who use the service experience good quality outcomes in this area. Procedures for the recruitment of staff have improved. A training programme provides staff members with the basic skills for meeting the needs of people living at the home. EVIDENCE: The owner lives at and manages the home and carries out the majority of shifts. There is usually only one staff member on duty at any time due to the small size of the service. We looked at records for six members of staff who work at the home part-time or occasionally. Procedures have been improved since the March 2007 inspection and contained all necessary documentation including a Criminal Records Bureau (CRB) check. Records showed that there has been training for some staff members in Food Hygiene, Fire Safety and Safeguarding Adults. Two staff have completed the NVQ Level Two qualification and one person is studying for this award. As stated previously, one newer member of staff needs to attend training around Safeguarding Adults. As stated previously, it is recommended that the owner looks at accessing further training around activities, dementia and person centred care in order for the service to develop. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 17 The owner is a Registered General Nurse and has a Certificate in Management. She stated that she is intends to complete two further modules in management training in order to meet the level of Management training equivalent to NVQ Level Four. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 18 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36 and 38. People who use the service experience adequate quality outcomes in this area. Health and Safety issues are generally adequately addressed by the home. The views of people living at the home are sought informally on an ongoing basis. EVIDENCE: The owner continues to live at and manage the service. She clearly knows the individuals living there well and works hard to meet the National Minimum Standards. Records showed that there are regular safety checks for hot water, fridge temperatures and fire equipment. The owner has made sure that checks have taken place around electrical equipment and legionella as asked for at the Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 19 March 2007 inspection. A Requirement has been made from this inspection visit to make sure that an annual Gas Safety check has taken place. Consultation with individuals living at the home is generally informal with their views being obtained on an ongoing basis. Written surveys are also sent out by the owner annually to seek people’s views on the service provided. The owner said that individuals living there do not wish to take part in regular meetings. We looked at the financial records kept for one person. These were satisfactory but we have recommended that the arrangements in place are looked at during their next review with the responsible Local Authority care manager. This is to make sure that charges being made for disposal of clinical waste and escorts outside of the home continue to be agreed by all parties. Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 2 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 2 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 X X X X 3 X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 2 Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No 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 OP3 Regulation 14 (2) (a) (b) Requirement In order to ensure that the changing needs of individuals are met, assessments must be kept under review and revised as necessary. Care plans must address social care needs. This will ensure that this important area of need is looked at and reviewed on a regular basis. Full records of the food provided must be kept by the home. This will enable individual diet to be looked at and properly assessed as necessary. In order to help safeguard people living at the home, all care staff must have received training in Safeguarding Adults (POVA). The rusty handrail in the first floor bathroom must be replaced to make sure the safety of individuals is protected. In order to protect the health and welfare of people living there, an annual Gas Safety check must be carried out and a copy of the certificate supplied to the CSCI to evidence this. Timescale for action 01/08/07 2. OP7 15 (1) 01/09/07 3. OP15 17 (2) 01/08/07 4. OP18 13 (6) 01/10/07 5. OP19 23 (2) (b) 01/08/07 6. OP38 13 (4) 01/07/07 Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 22 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 OP8 Good Practice Recommendations It is strongly recommended that a referral is made to the local continence service via the GP. Advice and new equipment should be obtained for persons living at the home. It is recommended that the owner and / or staff members attend training in the new Local Authority Safeguarding Adults procedure as it becomes available. It is recommended that the kitchen be renovated. The owner should look at accessing training around activities, dementia and person centred care. The financial arrangements in place for one person should be looked at during the next review involving the responsible care manager. This is to make sure that charges for clinical waste disposal and escorts outside the home continue to be agreed by all parties. 2. 3. 4. 5. OP18 OP19 OP30 OP35 Liverpool Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Croydon, Sutton & Kingston Office 8th Floor Grosvenor House 125 High Street Croydon CR0 9XP 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 Road (23) DS0000028100.V340372.R02.S.doc Version 5.2 Page 24 - 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. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!