Inspection on 09/03/07 for Liverpool Road (23)

This inspection was carried out on 9th March 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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 but made no statutory requirements on the home.

Other inspections for this house

Liverpool Road (23) 21/05/07

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 Diane Thackrah Key Unannounced Inspection 9th March 2007 11:35 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.V331018.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 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.V331018.R01.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.V331018.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 3rd February 2006 Brief Description of the Service: Beatitudes, 23 Liverpool Road, is situated in a quiet residential area in Thornton Heath. It is near the shopping centre and well placed for transport links to local amenities and nearby Croydon town. Beatitudes is registered to provide care and accommodation for three older people and operates very much as a small family type home. Service users each have a single bedroom and adequate shared communal space, including a lounge and dining area. There are two toilets and one bathroom. There is a small rear garden with lawn and paved areas. A copy of the service’s Statement of Purpose and Service User Guide can be obtained on request from the Registered Provider. Fees for the home at the time of writing are £400 per week additional charges are made for the use of escorts and the disposal of clinical waste. Liverpool Road (23) DS0000028100.V331018.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 on 9th March 2007 between 11.35 and 15.30. A partial tour of the premises took place and care records were examined. Observations of care practices also occurred. The Registered Provider and one staff member was spoken with as were both of the service users who are currently living in the home. The views of two General Practitioners connected with the home have been received via comment cards. The views of these people will be reflected in this report. What the service does well: What has improved since the last inspection? What they could do better: Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 6 Seven Requirements have been made as a result of this inspection. Improvements are required in the way that medication is being recorded on Medication Administration Records, currently, it is unclear what medication has been prescribed to service users. It is of serious concern that one staff member has been employed to work in the home without the Registered Provider carrying out any vetting. Another staff member has been employed without a new Criminal Records Bureau check having been made. It is also of concern that records and receipts have not been kept in relation to the expenditure of service user’s money. Some areas of the home are poorly maintained including the kitchen and the carpet in one service user’s bedroom. Improvements must be made in these areas. There is a need to carry out testing for legionella and safety testing on electrical appliances in the home. Additionally, there must be a fire risk assessment carried out on the premises. 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.V331018.R01.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.V331018.R01.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): Quality in this outcome area is good. (3 and 6) This judgement has been made using available evidence including a visit to this service. There are appropriate arrangements for obtaining information about the needs of service users before they move into the home, which allow these needs to be met. The home does not provide intermediate care. EVIDENCE: There have been no new admissions in the home since the last inspection; needs assessment documentation was therefore not examined. Previous inspections have highlighted that needs assessments have been obtained and completed appropriately. Liverpool Road (23) DS0000028100.V331018.R01.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): Quality in this outcome area is good. (7, 8, 9 and 10) This judgement has been made using available evidence including a visit to this service. There continue to be good arrangements for care planning and service users continue to have their health, social and personal care needs well met. The arrangements for handling medication must be improved in order to protect the well being of service users. An emphasis is placed on protecting the dignity, and respecting the privacy of service users ensuring that service users have a good quality of life. EVIDENCE: There was positive feedback from both service users. Positive comments were also received from two General Practitioners who visit the home. Care plans seen were appropriate and in line with National Minimum Standards. They described the needs of the service users, and how staff members should address these. They detailed how staff members should support service users to retain a degree of independence. Appropriate risk assessments were in Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 10 place and there were records detailing that care plans had been reviewed regularly. Care records seen detailed that service users have access to a range of health care professionals and that the home is proactive in arranging health care appointments. There were records detailing that service users are registered with a general practitioner, have their weight monitored regularly and see opticians and dentists as necessary. One service user was escorted to a health appointment at the time of this inspection. Medication Administration Records examined were, generally, in good order. There was, however, one Medication Administration Record that detailed that the service user had been administered medication, but this was not available in the home. The Registered Provider said that this medication had in fact been discontinued. Medication Administration Records must accurately reflect all medication being taken. A Requirement is made regarding this issue. Service users were treated with dignity and respect throughout this inspection. Liverpool Road (23) DS0000028100.V331018.R01.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): Quality in this outcome area is good. (12, 13, 14 and 15) This judgement has been made using available evidence including a visit to this service. There continues to be a varied activities programme and wholesome and enjoyable meals are provided; therefore differing expectations and lifestyles are well catered for. EVIDENCE: Service users continue to have opportunities for social and recreational activities. Both service users attend a local day centre during the week. Guests are welcome in the home. Some structured activities, such as quizzes are facilitated however; the Registered Provider said that service users usually prefer to spend their time watching television. At the time of this inspection, service users were watching television in the lounge whilst a staff member was listening to the radio in the adjoining kitchen. The radio could be heard in the lounge. It is the opinion of the writer that this could be distracting for the service users. The service users should be consulted with regarding this issue and the radio should not be used if it is found to be distracting. The home has a garden and care records detailed that service users have enjoyed spending time in it during the summer months. There are opportunities for service Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 12 users to engage in religious observance and staff members spend time with service users and ensure that they have opportunities to make decisions about day-to-day life in the home. There was positive feedback about food served in the home from one service user. Meals seen looked nutritious and well presented and a meal time was relaxed and unhurried. A weekly menu available detailed that meals provided are varied. The Registered Provider said that there is always a choice at meal times and that service users could eat whatever they liked. Service users were offered a choice of what they ate during this inspection. Drinks and snacks were provided to service users throughout the inspection. Liverpool Road (23) DS0000028100.V331018.R01.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): Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. The home has systems in place for dealing with complaints. This ensures that service users and their family members know that their complaints will be taken seriously. There are failures in the home’s staff recruitment procedures. They are not robust, and therefore people living in the home are not fully protected from abuse. EVIDENCE: The home has a complaints procedure, which is made easily available in the Service User Guide. The Registered Provider said that no complaints have been made since the last inspection of the home. A procedure for responding to allegations of abuse is available in the home and records indicate that staff members have undergone training in the protection of vulnerable adults. There has been a failure by the Registered Provider to carry out vetting for some staff members. It is concerning that the most recently employed staff member was employed to work in the home without two written references, Criminal Records Bureau or Protection of Vulnerable Adults List checks. This staff member was working unsupervised at the time of this inspection. Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 14 Another staff member has been employed without a new Criminal Records Bureau check being undertaken. An Immediate Requirement has been issued regarding these poor staff recruitment procedures. Staff members must not work in the home unless all required vetting has been undertaken. Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 15 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): Quality in this outcome area is adequate. (19, 24 and 26) This judgement has been made using available evidence including a visit to this service. The home is, in general, maintained, decorated and furnished to an adequate standard. However, there is a need for some environmental improvements to ensure that comfort, health and safety is maintained. EVIDENCE: This is a small, family run home. Previous inspections of the home have found it to comply with the requirements of the London Fire and Emergency Planning Authority and Environmental Health department, but there have been no recent visits. Fire detection and fire fighting equipment is situated throughout the home and there are regular tests on this equipment. The kitchen is in need of repairs as a number of the cupboard doors are falling off their hinges. The Registered Provider stated that she intended to replace the kitchen later in the year. It is positive to note that a conservatory has newly been built onto the home. This will be used as an additional day room for service users. Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 16 Service user’s bedrooms were seen and both were clean and tidy and had been personalised. One bedroom had a very worn carpet. It is acknowledged that this is due to the Registered Provider’s good efforts to kept the carpet clean and fresh smelling, however, the carpet appears scruffy and must be replaced. All areas of the home were clean and tidy. Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 17 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): Quality in this outcome area is or poor. (27, 28, 29 and 30) This judgement has been made using available evidence including a visit to this service. There has been a failure to ensure that the procedures for the recruitment of staff are robust. Therefore, people living in the home are not fully protected from abuse. There is a staff training and development programme that provides staff members with skills necessary for meeting the needs of service users. EVIDENCE: As this is a small home, generally there is only one staff member on duty at any time. At the time of this inspection this number appeared to be adequate, and in line with the current needs of the service users. The Registered Provider lives at the home, and therefore carries out the majority of shifts. Records were available detailing that there has been training for some staff members in Infection Control and Moving and Handling. The Registered Provider is a Registered General Nurse and has a Certificate in Management. It is necessary that the Registered Provider complete two further modules in management training in order to meet the required level of Management training to meet this Standard. She has stated her intention of doing so. Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 18 There are poor procedures for staff recruitment. The Registered Provider has failed to obtain necessary checks of some staff members working in the home and therefore failed to offer protection to service users. This issue is discussed in further detail in Standard 18 of this report. An Immediate Requirement has been issued to the Registered Provider. A failure to comply with this may result in enforcement action being taken by the Commission. Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 19 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): Quality in this outcome area is adequate. (31, 33, 35 and 38) This judgement has been made using available evidence including a visit to this service. There is a quality assurance system, including staff supervision, which focuses on best outcomes, however there is a need for improvements in order to ensure that the home is run in the best interests of service users. Health and safety is, in general, taken seriously. However, improvements must be made in order to ensure that the well being of service users is fully promoted and protected. EVIDENCE: The Registered Provider continues to manage the service. Generally there is good management and service users state that they are content with life in the Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 20 home. This Standard is not considered met however, due to the Registered Provider’s failure to follow safe recruitment practices. Service users and their family members are surveyed on a regular basis about their views on the home and the results of a recent survey were available for inspection. There were records detailing that staff meetings occur. Records also detailed that service users meetings have occurred in the home in the past. The Registered Provider said that current service users do not wish to take part in regular meetings. The Registered Provider handles money on behalf of each service user. It was therefore disappointing that there were no records detailing any spending and no receipts. There must be a clear record detailing all spending on behalf of service users by the Registered Provider. Receipts must be maintained There were records detailing that staff members are trained in safe working practices such as moving and handling, food hygiene, infection control and first aid. Records also indicated that there are regular safety checks on water temperatures, fridge and freezer temperatures and fire fighting equipment. There were no records detailing that portable electrical appliances in the home have been safety checked, this must occur. Nor were there records’ detailing that testing for legionella has occurred. There are risk assessments in place for chemicals and all accidents and incidents are recorded. There were records detailing that the fire alarm has been tested on a regular basis throughout this year. It is positive that the Registered Provider has addressed the Requirement made at the last inspection of the home regarding the need for the fire evacuation procedure to be updated. It is necessary however for the Registered Provider to carry out a fire risk assessment of the premises. Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 21 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 1 3 X X X X 2 X 3 STAFFING Standard No Score 27 X 28 X 29 1 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X 3 3 X 2 Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13 (2) Requirement The Registered Provider must ensure that Medication Administration Records detail only the current medication being taken by a service user. The Registered Provider must not employ anyone to work in the home unless a satisfactory Criminal Records Bureau check, Protection of Vulnerable Adults check and two written references have been obtained. (A new Criminal Records Bureau check must be applied for in the case of one staff member were a new Criminal Records Bureau check was not obtained by the Registered Provider) Immediate Requirement issued. The Registered Provider must replace the worn carpet in the ground floor bedroom. The Registered Provider must ensure that there is a clear record detailing all spending on behalf of service users by the Registered Provider. Receipts must be maintained DS0000028100.V331018.R01.S.doc Timescale for action 01/04/07 2. OP18 19 (1)(a)(b) (i) 09/03/07 3. 4. OP19 OP35 23 (2)(d) 12 (1)(a) 01/05/07 01/04/07 Liverpool Road (23) Version 5.2 Page 23 5. OP38 12 (1)(a) 13 (4)(a) The Registered Provider must ensure that: 1. An up to date electrical installation certificate is available for inspection. 2. Up-to-date records of portable appliance safety checks are available for inspection. The Registered Provider must ensure that there is testing for legionella in the home. The Registered Provider must ensure that there is a fire risk assessment that is dated and reviewed at least yearly. 01/05/07 6. 7. OP38 OP38 12 (1)(a) 12 (1)(a) 23 (4)(a) 01/06/07 01/05/07 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 Refer to Standard OP12 Good Practice Recommendations Service users should be consulted with regarding the radio being played at the same time that television is being watched and the radio should not be used if it is found to be distracting. Liverpool Road (23) DS0000028100.V331018.R01.S.doc Version 5.2 Page 24 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.V331018.R01.S.doc Version 5.2 Page 25 - 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!