Inspection on 10/04/07 for New Hutte Lane, 9

This inspection was carried out on 10th April 2007.

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 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

New Hutte Lane, 9 26/05/06

New Hutte Lane, 9 20/02/06

New Hutte Lane, 9 18/08/05

New Hutte Lane, 9 24/01/05

New Hutte Lane, 9 02/08/04

New Hutte Lane, 9 02/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 New Hutte Lane, 9 9 New Hutte Lane Halewood Liverpool Merseyside L26 9UD Lead Inspector Daniel Hamilton Unannounced Inspection 10th April 2007 8:30 New Hutte Lane, 9 DS0000021495.V334903.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 New Hutte Lane, 9 DS0000021495.V334903.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. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service New Hutte Lane, 9 Address 9 New Hutte Lane Halewood Liverpool Merseyside L26 9UD 0151 291 9139 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) Brothers of Charity Mrs Sheila Elizabeth Fitzpatrick Care Home 3 Category(ies) of Learning disability (3) registration, with number of places New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to Include up to 3 (LD) The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 26th May 2006 Date of last inspection Brief Description of the Service: 9 New Hutte Lane is a detached bungalow, which is situated in the Halewood area of Liverpool. The property is owned by ‘Brothers of Charity’, a Registered Charity, which is registered to provide personal care and support to the three people living in the home. The people who use the service have severe learning disabilities and moved to the home following the closure of a long-term institution some time ago. The home is spacious and has a lounge, dining area, kitchen, bathroom, wet room / shower area, four bedrooms (one is used by staff for administration and sleeping in duties) and a garden. The home is accessible via a ramp and the rear garden is adapted for people who have physical disabilities and visual impairments. A purpose adapted mini bus is available for outings and appointments. The Care Home Fee is set at £1278.00 per week. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place over one day and lasted approximately 7 hours. Three people were living in the home at the time of the visit. A tour of the premises took place and observations were made. A selection of care, staff and service records were also viewed. The Registered Manager, three staff members and an advocate was spoken with during the inspection. Time was spent with each of the people using the service before they visited day care services and / or undertook individualised activities. The people were encouraged to participate in the inspection process using their preferred methods of communication. The Registered Provider’s head office was visited as part of the inspection in order to check staff recruitment and training records. Feed back on the inspection findings were also discussed with the Organisation’s Area Director during the visit. What the service does well: 9 New Hutte Lane had been decorated and furnished to a good standard and the people using the service appeared relaxed and comfortable in their home environment. Essential Lifestyle and Support Plans had been developed to ensure each person’s needs, wishes, preferences and personal goals had been identified and planned for. Staff spoken with during the visit demonstrated a good awareness of the needs of the people they cared for, equality and diversity issues, the principles of good care practice and safe working practices. An advocate reported; “The men appear to be well looked after.” The people using the service were encouraged to participate in a range of activities and to maintain relationships with their peers and any family members involved. Records showed that the people living in the home had enjoyed two holiday breaks during the previous year. Staff had access to induction, training and supervision as part of their employment to ensure they were supported to undertake their role effectively. Furthermore, systems had been established to correctly recruit staff and to protect vulnerable adults from abuse. There had been no complaints since the last visit. A relative / advocate confirmed he was aware of how to make a complaint about the care provided by the home and that the service had always responded appropriately when any concerns had been raised. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: Some risk assessments viewed detailed a number of hazards and / or risks under one heading. Identified risks/ hazards should be individually assessed to ensure they are appropriately planned for. Activity records for one individual were brief and did not always provide sufficient information on the activity provided and /or outcome. For example, records detailed that a person had been on numerous “trips out” but there were no details of the destination and / or outcome. Records should be updated to include this information to clarify how the home meets the recreational needs of all the people using the service. Despite a recommendation at the last visit, deserts had not been recorded for the majority of meals served and examples of poor menu planning were viewed during the visit. The home should develop a menu plan, based upon the dietary needs and preferences of the people using the service, to ensure people receive a varied and balanced diet. Some Health Action Plans had not been kept under review and the outcomes / results had not always been recorded. Some weight records viewed did not detail the year and a risk assessment had not been completed to address the risks associated with supporting a person with pedicure care. Health care records and associated documentation should be updated to confirm the health care needs of the people using the service are appropriately met. Following a requirement at the last visit, the manager had made arrangements for the date, quantity and initials of staff receiving medication into the home to be recorded for medication that was not contained within a blister pack system. The manager should ensure that the date and quantity of all medication entering the home is recorded and checked to ensure an audit trail. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 7 A copy of the local authority adult protection procedures could not be located and should be obtained for the manager and staff to reference. This will ensure an appropriate response to suspicion and / or evidence of abuse. At the time of the visit 50 of the home’s care staff did not have a National Vocational Qualification (NVQ) in Care at level 2 or above. Furthermore, the manager did not have a NVQ in Care at level 4. Arrangements should be made to ensure the manager and staff complete the necessary training to develop competence and ensure compliance with National Training targets. Records showed that Regulation 26 reports had been completed by the Registered Manager. The Registered Provider should ensure the visits and reports are not undertaken by the Registered Manager, to ensure compliance with Regulation 26. 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. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1 and 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The service had developed a range of accessible information, to enable current and prospective people to choose a home that could meet their needs and expectations. EVIDENCE: The three people who used the service had lived in the home for approximately 11years. There had been no new admissions since the last visit. Each person living in the home had a personal file. Two files were viewed and both contained a copy of an original ‘Community Nursing Assessment’, which had been completed for each individual before they moved into the home. The needs of the people living in the home had been kept under review as part of Essential Lifestyle Planning processes (a person centred approach to care planning). Evidence from the previous inspection confirmed the Registered Provider (Brothers of Charity) had developed a ‘Statement of Purpose’ and ‘Service User Handbook’ which contained key information on the service provided. The information had been designed with pictures, signs and symbols to ensure the format was geared towards the needs of people with learning disabilities. ‘Contract of Agreement’ documents were also available on files. New Hutte Lane, 9 DS0000021495.V334903.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 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The changing needs of service users were generally recognised, planned for and supported to promote independence, wellbeing and choice. EVIDENCE: The personal files of two of the people living in the home were viewed. Each file contained an ‘Essential Lifestyle Plan’ and ‘Private Plan’. The plans contained appropriate information on each individual’s needs, wishes, preferences and personal goals, together with key information on each person’s support requirements. Plans had been kept under regular review. Supporting documentation including; pen pictures, risk assessments, total communication and daily routine plans, learning logs, daily reports, activity sheets, incident and accident records, health care records, personal records and general correspondence were also in place as noted at the last visit. The people living in the home had little or no verbal communication. Staff spoken with demonstrated a good understanding of the needs of the people they cared for and were able to explain how they observe and monitor each New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 11 person’s wellbeing, feelings and preferences by looking at body language, responses and gestures. Staff were observed being kind and helpful towards the people in the home during the visit. The people using the service appeared relaxed and comfortable in their home environment and were seen to respond positively to staff interaction by smiling, touching, gestures and / or responsive sounds. Staff spoken with demonstrated a good knowledge of each person’s essential lifestyle plan and their needs, preferred routines and preferences. Staff were observed to treat the people using the service with privacy and dignity during the visit and confirmed they had received training in equality and diversity issues and the principles of care. The people in the home were encouraged to take appropriate risks associated with the normal aspects of daily life whenever possible. Appropriate action was taken by staff to minimise potential and actual risks and staff support was available at all times. A range of individual risk assessments had been completed for each person using the service in order to address environmental, health and safety and personal risks. One risk assessment viewed had been updated since the last visit and did not adequately identify risks and / or control measures, as several risk areas had been grouped together under one heading. This practice should be reviewed as it has the potential to cause confusion and for risks not to be appropriately managed. New Hutte Lane, 9 DS0000021495.V334903.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): 12, 13, 14, 15, 16 and 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Overall, the service enabled the people living in the home to become involved in everyday experiences and opportunities. Menu planning was in need of review to ensure the people in the home enjoy a healthy diet and lifestyle. EVIDENCE: The manager reported that there had been no changes to the weekly routines of the people living in the home since the last visit. Two of the people using the service continued to attend a day centre each week and this enabled them to participate in a range of activities with their peers. Activity records viewed showed that the people using the service had taken part in various leisure and recreational activities including; swimming, drives out, walks to the shops, visiting the pub, relaxing in the home and gardens, shopping, football and visiting places of interest. A ‘Community Partner’ continued to assist one of the people to access community based activities. As noted at the last visit, one person did not interact as well as the other people living in the home due to having complex support needs. Some activity New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 13 records viewed did not always provide sufficient detail of the activities the person had participated in and the majority of activities focussed on trips out in the home’s minibus. This was discussed with the manager during the visit. Discussion with the manager and staff revealed that the people using the service had been supported on two holidays during 2006. The first holiday was a 5-day break in Wales and the second was a long weekend break in the lakedistrict. Photographs of the holiday were viewed during the visit. The home continued to use ‘Learning logs’ to record opportunities for personal development such as developing independent living skills. Logs recorded information on the activity undertaken, the aims of the activity and details of who provided the support. The manager and staff spoken with demonstrated a good awareness of the rights and responsibilities of the people using the service. Essential Lifestyle Plans detailed all the important people in the lives of each person, contact details and the support required to maintain fulfilling relationships. As noted at the last visit, one person was in regular contact with a relative who also acted as an advocate for the other people living in the home. The advocate was contacted as part of the inspection process and overall was complimentary of the service provided. Comments included; “All the staff seem to really take good care of their charges”, “The men appear to be well looked after” and “I think the service has improved.” The manager reported that the home continued to receive a weekly food budget (including cleaning materials) of £100.00 pounds. A menu plan had not been developed and a record of deserts had not been recorded as recommended at the last visit. The manager was recommended to develop a menu plan as examples of poor menu planning were noted. For example, records showed that on one date a person living in the home was served “Broth and Juice” for lunch and then received “Chicken Soup and Juice” for tea. On another occasion, a person was served “Scrambled Egg, Toast and tea” for breakfast and then received “Toast, Scrambled Egg and juice” for lunch. Other examples were noted and discussed with the manager during the visit. Food stocks were satisfactory at the time of the visit. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The people living in the home received person centred care and support. Some healthcare records were in need of review to confirm the healthcare needs of service users are fully met. EVIDENCE: Information on the personal care and support needs of the people living in the home had been recorded in Essential Lifestyle and Private plans. Staff spoken with during the visit were aware of the need to treat individuals with respect and to consider dignity when providing personal care. Staff were observed to apply these principles in practice during the visit.. Files viewed contained a ‘Health Action Plan’, which detailed how the general health care needs of individual service users were to be met during the year. One health action plan was in need of review as it was dated February 2006 and some outcomes / results had not been recorded. Furthermore, weight records viewed did not detail the year. Health Action Plan diary notes viewed provided evidence of input from a range of health care professionals including; doctors, psychiatrists, practice nurses, chiropodists, opticians and dentists. Records viewed had not always been updated following appointments and there was limited information on the New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 15 outcomes of some appointments. The manager reported that some health related appointment records had been sent to head office and were due to be returned to the home. The manager was advised to complete a risk assessment for one of the people living in the home, as staff had been designated responsibility for assisting the person with chiropody care. The home had a copy of the organisation’s medication policy. This was entitled; ‘Enabling and Support of Service Users with Learning Disabilities in the Administration of Medicines and Health Related Activities.’ Separate guidance on when to give medication that was “give as required” was also in place at the previous visit. Training records showed that staff responsible for the administration of medication had completed training and this was confirmed in discussion with staff. None of the service users self-administered medication. The home used a blister pack system that was dispensed by Boots pharmacy. Medication was stored in a lockable cabinet in the staff bedroom. The manager reported that no controlled drugs were being stored on the premises. Medication Administration Records (MAR) were viewed for each person. Since the last visit the manager had started to record details of the date and quantity of medication entering the home on MAR for medication that was not included in the blister pack system. Furthermore, MAR viewed had been correctly completed to account for the administration of medication. The manager was advised to record this information for all medication received into the home and to date medication boxes when opened, to provide a clear audit trail. Daily balances of medication had been recorded by staff using a separate record. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Systems had been developed to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: The home had a complaints procedure, which had been developed by the Registered Provider (The Brothers of Charity). A full version was available in the office/ staff bedroom and a laminated version was displayed on the wall of the office. Complaints were dealt with at the main site of the organisation in Huyton. The relative of one of the people using the service (who also acted as an advocate for the other people living in the home) was contacted as part of the inspection process. The relative / advocate confirmed that he was aware of how to make a complaint about the care provided by the home and that the service had always responded appropriately when any concerns had been raised. The relative / advocate reported that he felt listened to and that he had confidence that any issues would be addressed. The complaints record book for the home was viewed. This showed that no complaints had been received since the last inspection. Likewise, the Commission for Social Care Inspection had received no complaints about the service. The agency had developed a ‘Protecting People from Abuse Policy’ and a ‘Whistleblowing’ policy was also available for staff reference. Training records showed that staff had completed Protection of Vulnerable Adult training. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 17 Staff spoken with demonstrated knowledge and understanding of how to recognise and respond to abuse. The manager was advised to obtain a copy of the local authority’s adult protection procedures for staff to reference, as a copy could not be located at the time of the visit. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 18 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 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is pleasant and well maintained. This provides the people living in the home with a safe, clean and comfortable environment. EVIDENCE: The Registered Provider (Brothers of Charity) continued to be responsible for the maintenance of the property. A maintenance book was in place to record hazards / work requiring attention and records were available to confirm that the staff team undertook quarterly health and safety inspections. Since the last inspection the home had been completely redecorated and the manager reported that funding had been secured for new carpets to be fitted throughout the property. Handrails had also been fitted around the home to assist a person with profound and multiple learning disabilities. Maintenance issues identified at the last visit had also been addressed. All areas of the home including the bedrooms were viewed. Overall, the property appeared to be maintained to a good standard and provided the people using the service with an accessible, safe and comfortable environment in which to live. Radiators had been guarded and the manager confirmed that New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 19 the bathrooms were fitted with thermostatic valves to regulate the temperature of the hot water. Rooms viewed had been personalised and photographs of the people living in the home were displayed around the home. The garden was also well maintained and accessible. (Please refer to the brief description of the service section for more information on the property). Staff were responsible for cleaning and cooking in the home. Cleaning schedules had been developed and staff were observed to be undertaking cleaning duties during the inspection. Records showed that staff had completed health and safety, infection control and food hygiene training. Control of Substances Hazardous to Health (COSHH) guidelines were in place and data sheets were available for staff to reference. The manager confirmed that chemicals / cleaning products were safely stored in the home’s kitchen. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 20 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, 34 and 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The welfare of the people using the service is safeguarded as staff are correctly recruited and have access to a range of training opportunities. Some important training targets are in need of review, to demonstrate that staff are competent and qualified. EVIDENCE: Discussion with the manager and examination of the home’s staffing rota confirmed there were seven staff (excluding the manager) allocated to work in the home. The manager also worked shifts in the home as part of her duties. Examination of rotas, direct observation and discussion with the manager and staff confirmed that two staff were on duty through the day. At night, the home had one waking night staff and an additional staff member undertook sleep-in duties. The manager reported that the service operated a thorough recruitment procedure that was based upon equal opportunities. Recruitment was coordinated from the Organisation’s head office as noted at the last visit. Four new staff had started to work at the home since the last visit as a number of staff had left or transferred to another home. The manager acknowledged New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 21 the importance of keeping the team as stable as possible in the future, to ensure continuity of care for the people living in the home. Employment / Recruitment Records were stored at the Organisation’s Head Office which was visited as part of the inspection. Records were available to confirm the necessary pre-employment checks had been obtained by the Registered Provider for all the new staff. Training records viewed did not provide any information on which staff had completed a National Vocational Qualification (NVQ) in Care at level 2 or equivalent. The manager reported that three of the staff (42.5 ) had completed a NVQ in Care however a certificate was available for only one member of staff (14.28 ). None of the other staff were working towards the award at the time of the visit. The manager reported that the home had previously achieved the target for 50 of the care staff to achieve a NVQ level 2 in Care. The manager explained that the loss of four qualified staff had contributed to the target no longer being met. A ‘Training Needs Analysis’ record had been completed. This provided details of the training completed by all staff except one. Records showed that the Organisation (Brothers of Charity) continued to provide staff with a good range of training opportunities to develop knowledge, skills and understanding. Staff spoken with confirmed they had received an induction and completed a range of training that was relevant to their role and responsibilities. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 22 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): Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Management systems had been established and / or being developed to ensure protect health and safety and to obtain the views of people using the service and / or their representatives. EVIDENCE: Since the last inspection, the Commission for Social Care Inspection had Registered Sheila Fitzpatrick as the manager of the home. Mrs Fitzpatrick had previous experience in the management of a small care for people with learning disabilities. Mrs Fitzpatrick had completed the level 4 National Vocational Qualification (NVQ) Registered Managers Award and training records showed that she had also undertake a range of training that was relevant to her role. At the time of the visit, Mrs Patrick had not completed a level 4 NVQ in Care and was reminded that this qualification is also needed for a Registered Manager. Records showed that the Registered Manager had undertaken monthly Regulation 26 reports on behalf of the Registered Provider. The manager was New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 23 advised that this duty should be completed by an employee of the organisation who is not directly concerned with the conduct of the care home. Since the last visit, the Organisation (Brothers of Charity) had developed a new quality assurance framework. There was evidence that a quality assurance assessment had taken place for the home in July 2006 and the findings had been compiled to produce an action plan. Progress with the action pan had been reviewed during the year. No information on the quality assurance system was available for reference at the time of the inspection. The area director reported that the Organisation was in the process of reviewing the documentation to ensure it was produced in a format that was suitable for people with learning disabilities. The manager was advised to consider the use of independent advocates in the quality assurance process as records detailed that; “All service users’ questionnaires were completed by the staff as the service users would not be able to do so.” The organisation had produced a health and safety file, which contained a range of policies and procedures to promote safe working practices and compliance with health and safety legislation. Staff spoken with reported that they had received training in Safe Working Practice subjects in order to safeguard the health and safety of the people living in the home. Health and Safety checklists had been completed every three months to monitor the condition of the home. Pre-inspection records detailed that equipment and services within the home had received maintenance and inspection. Since the last visit, the electrical wiring in the home had been checked and a certificate obtained and hot water temperature records had been established. Certificates were also available for gas safety and fire extinguisher servicing. Portable Appliance Testing had been completed however a certificate had not been produced. Fire records were viewed for the property. These showed that the smoke detectors were tested on a weekly basis and that a fire drill had been undertaken during March 2007. A fire and generic risk assessment had also been completed. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 24 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 4 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 2 33 3 34 X 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 2 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 2 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 3 X X 3 X New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 25 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. Standard Regulation Requirement Timescale for action 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 3 Refer to Standard YA9 YA14 YA17 Good Practice Recommendations Risk assessments should be reviewed to ensure conflicting hazards / risks are not grouped together under one heading. Activity records should detail more information on the activities provided and the outcomes for people using services. A menu plan should be developed that is based upon the dietary needs and preferences of the people living in the home. This will help to avoid repetition and ensure the people receive a varied, balanced and nutritious diet. Records of deserts should be recorded. Health Action Plans should be kept under regular review and the outcomes / results should be recorded. Weight records should specify the year of appointments. A risk assessment should be completed to address the risks associated with supporting a person with pedicure care. The date, quantity and initials of the person receiving DS0000021495.V334903.R01.S.doc Version 5.2 Page 26 4 5 6 7 8 YA17 YA19 YA19 YA19 YA20 New Hutte Lane, 9 9 10 11 12 YA23 YA32 YA37 YA39 13 YA39 medication into the care home should be recorded on Medication Administration Records for all medication received into the home. The home should obtain a copy of the Local Authority’s Adult Protection Procedures. At least 50 of the care staff working in the home should be trained to a National Vocational Qualification in Care at level 2 or above. The Registered Manager should complete a National Vocational Qualification at level 4 in Care Regulation 26 visits and reports should be undertaken by an employee who is not directly concerned with the conduct of the care home to ensure compliance with the regulation. The home should consider the use of independent advocates as part of the quality assurance system. New Hutte Lane, 9 DS0000021495.V334903.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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. 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