Inspection on 11/06/07 for Salisbury Park (31)

This inspection was carried out on 11th June 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 found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Salisbury Park (31) 31/08/06

Salisbury Park (31) 09/01/06

Salisbury Park (31) 21/07/05

Salisbury Park (31) 17/01/05

Salisbury Park (31) 12/05/04

Salisbury Park (31) 03/02/04

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 Salisbury Park (31) 31 Salisbury Park Woolton Liverpool Merseyside L16 0JT Lead Inspector Beate Field Key Unannounced Inspection 11th June 2007 09:15 Salisbury Park (31) DS0000025164.V335428.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 Salisbury Park (31) DS0000025164.V335428.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. Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Salisbury Park (31) Address 31 Salisbury Park Woolton Liverpool Merseyside L16 0JT 0151 722 9729 0151 722 9729 salisburypark@c-i-c.co.uk www.c-i-c.co.uk. Community Integrated Care 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) Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 16th February 2007 Brief Description of the Service: 31 Salisbury Park is a care home registered with CSCI to provide care and support to three adults with a learning disability. The home is run by Community Integrated Care. Salisbury Park is situated in a residential area of Woolton in Liverpool and is close to local amenities, bus and rail routes. Salisbury Park is a bungalow. Residents have their own bedrooms and access to two shared shower rooms. There is limited access to one of these shower rooms due to its size and position within the home. There is a large lounge with a dining area, kitchen, laundry room and a large garden to the rear of the home. Residents have purchased their own vehicle, which gives them the opportunity to access community facilities and go further a field. Parking is available for staff and visitors on the road outside the home. At the time of the inspection, the weekly cost for the service was £692.00. A statement of purpose, which describes the services offered at 31 Salisbury Park, is available for relatives and social and health care professionals to refer to. A service user guide is available. Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection took place over 6 hours and is based on a visit to the home, information received about the service since the last inspection and by a questionnaire completed by the manager. During the site visit to the home time was spent in the office looking at a sample of records and policies and procedures and talking to the manager. A tour of the home was undertaken. The inspector spoke with staff and made observations of staff delivering care to the residents. What the service does well: What has improved since the last inspection? Since the last inspection a manager has been appointed who is in the process of making an application to CSCI to be registered as the manager for the service. There has been an improvement to the record keeping around medication. A stock count of medication is now being made which allows for an audit of medication to take place. Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2, 4 and 5 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The assessment process would ensure that the service is only offered to individuals whose needs can be met at the home. Residents are not fully supported by the terms and conditions they have with the home. EVIDENCE: There have been no new admissions to the service since the last inspection. The residents at 31 Salisbury Park have lived together for a number of years and prior to living at 31 Salisbury Park, they lived together in another of Community Integrated Care (CIC) homes in Cardwell Road. Should a vacancy arise a new admission would only take place following a full assessment by the service manager and the home’s manager in consultation with the prospective resident/representative and any relevant health care professionals. The prospective resident would be able to visit and a gradual move to the home would be planned. The initial assessment process indicates that the assessment process covers all of a residents’ needs including their communication, religious and cultural needs. There is a limited amount of information available about the lives of the current residents before they came to live at the home. Further information should be gathered as this will inform care planning for the residents. Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 9 Each resident has a copy of the statement of the terms and conditions with the home. These have not been signed. An individual who is independent of the home has not been involved in agreeing that the terms and conditions meet the residents’ best interests. The statement of terms and conditions do not cover all relevant matters such as who pays for holidays and who is responsible for furnishings and soft furnishings in residents’ bedrooms and communal areas. An examination of a residents finances showed they had paid for a curtain pole and curtains for their bedroom. As the contract is not clear on these matters staff have not got the information they need to ensure that residents monies are appropriately spent. The residents have a vehicle to enable them to access the community. A contract has been signed on the residents’ behalf by a senior manager from CIC indicating that the residents agree to their mobility allowance being used to acquire and run the vehicle. A relative or advocate was not approached to ascertain if this is in the residents’ best interests. The contracts/terms and conditions must indicate what residents are responsible for paying for and what is included in the cost of the fees paid to CIC. It is strongly recommended that an individual independent of the home agree that the contract/statement of terms and conditions meets the interests of the residents in accordance with their wishes and abilities. Salisbury Park (31) DS0000025164.V335428.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 adequate. This judgement has been made using available evidence including a visit to this service. There are clear care plans in place to provide staff with the information they need to satisfactorily meet residents’ needs, however, residents could be better supported by the arrangements for reviewing their care plans. Some further improvements need to be made to the behaviour management guidelines in order to ensure that staff are clear as to how they are to support residents. EVIDENCE: The home operates a key worker system and each resident has an Essential Lifestyle Plan (ELP), which, provides holistic information regarding their assessed needs, likes/dislikes, and personal goals. In addition, residents have a care plan, which documents how individual needs are generally met. Care plans are clearly written in a simple and easy to understand style. Both documents had been reviewed by the home in the last twelve months. Reviews have not been carried out with significant professionals, family, Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 11 friends or advocates. The manager reported that the residents have little contact with social or health care professional from the placing authority. There were no records to show that these individuals had been invited to attend a review or asked to comment on the residents current care plan. The manager reported that she is going to work with the staff and residents to identify personal goals to which residents can work towards. This information will be documented and reviewed. Some residents present challenges to the service and the guidelines are not detailed or specific regarding how staff are to respond to this. It is important that these guidelines are reviewed with an appropriate professional to ensure that the residents’ challenging behaviour is addressed correctly. The manager reported that staff have received training around the management of challenging behaviour. The residents are not able to communicate verbally and they do not have Makaton or other communication skills to convey their wishes. However, the staff team have developed an understanding of body language and gestures that are unique to each resident and have briefly recorded these in the care plans to help new and existing staff understand what the resident might be trying to say. The manager has identified that more detailed information needs to be recorded in the communication plans and is taking steps to address this. It was evident through observation that the staff team at the home respect the residents’ wishes. The staff spoken with were very knowledgeable about the needs of the residents and appeared to have a very good friendly relationship with them. Residents appeared relaxed and content with the staff. It is recommended that the residents have access to a local advocacy group to ensure that they can make independent decisions about their lives with assistance. Risk assessments are in place on the residents’ files and are reviewed regularly. They identify any particular hazards and give brief advice to staff on how they should be managed. These include: - environmental, health and handling risk assessments. The manager has identified that these risk assessments could be more detailed and is taking steps to address this. Salisbury Park (31) DS0000025164.V335428.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): 12,13,15,16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents take part in activities that provide opportunities for their social and personal development. The dietary needs of residents are well catered for with a balanced and varied selection of food being available that meets their tastes and choices. EVIDENCE: A weekly activity sheet was in place on each of the residents’ files. This forms the basis of activities but factors such as the weather and other events occurring in the home could mean that the programme is changed. Daily records indicate that the residents access a variety of activities. The home has television, radio and music facilities and residents enjoy spending time in the garden when the weather is good, going for walks, going to the cinema and eating out in pubs and restaurants. Other activities recorded included, help with shopping for food, visits to local places of interest, Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 13 quiet times in the house and shopping for personal items. The staff team go with the residents to the local shops and use community facilities such as pubs and cafés. On the day of the visit some residents were listening to music in the garden and a resident was watching television. A walk was planned for the afternoon. The manager is currently looking at better ways to deploy staff to enable residents to make greater use of activities that are further a field and to increase opportunities for residents to pursue their individual interests. Family contact is promoted where this is possible. Residents can see visitors in private in their bedrooms. Daily routines are flexible in accordance with the needs of the residents. The staff were observed interacting appropriately with the residents and treating them with respect. During the visit the residents moved freely around the home and spent time in the lounge and in their own rooms. There are menus displayed in the kitchen, but these are used as a guide. A record of the meals taken by residents is recorded in their personal records. Records showed that varied and nutritious meals are provided that meet the residents cultural needs. On the day of the visit the residents had a healthy lunch that was well presented and looked appetising. Residents’ food preferences and dislikes are recorded in their care plans. Salisbury Park (31) DS0000025164.V335428.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. In general the residents receive appropriate personal and healthcare support. However, in order to fully support residents and keep them safe the shower room facilities need to be reviewed and clearer epilepsy management guidelines need to be put in place. EVIDENCE: Care plans identify the ways in which personal care tasks should be undertaken for individual residents. It was observed that personal support is provided in private. The care plans include details of morning routines. The manager has identified that work is needed to fully record the evening routines of the residents. Residents are provided with personal care by male and female staff. Care plans should document the residents’ preferences with regards to which staff provide personal care, where this is possible. All the residents have a Health Action Plan. The residents’ records showed that residents have access to doctors, dentists and opticians when needed. The residents see a chiropodist every 2 months. Two of the residents were Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 15 overdue a hearing check-up. The manager said that this would be attended to without delay. The residents’ records contained guidance for staff on the management of epilepsy. Two epilepsy management plans were seen on each of the residents’ records. One of the plans was confusing and the guidance was not clear. The other did not contain information around the timescale for administering medication and the dosage. A clear epilepsy management plan needs to be put in place. All staff have received training around the management of epilepsy. A questionnaire completed by a general practitioner indicates that the residents’ health needs are always met. The residents have access to two shower rooms. One of the shower rooms is difficult to access as it is very small and the door opens directly on to a bedroom door. The main shower room used has a walk in shower, which is on one level. The flooring is made of hard quarry tiles. The manager reported that this results in his room becoming very slippy. There was an incident where a resident had a seizure and slipped on this floor causing redness to their back. An occupational therapist needs to be consulted regarding possible aids and adaptations in the shower room. Currently there is a low handrail. Advice on the flooring also needs to be obtained with a view to obtaining more appropriate flooring for the type of shower facility currently in use. None of the residents would be able to manage their own medicines. Medications are held securely. A check of medicines kept in the home identified that medications are being managed appropriately. A stock count is being undertaken. The manager reported that all staff have received medication training. This was confirmed by staff, although one member of staff is in need of refresher training. The manager has identified this and is to provide appropriate training. Salisbury Park (31) DS0000025164.V335428.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. The systems in place for managing complaints and adult protection matters ensure that the wellbeing of residents is safeguarded. EVIDENCE: There is a suitable complaints procedure, which gives the representatives of the residents a clear picture of how to raise a concern or complaint. There have been no complaints since the last inspection either at the home or at the CSCI Liverpool/Wirral office. The staff spoken with were aware of the content of the complaint procedure and how to respond to complaints. There is a corporate adult protection policy in place and the home also has a copy of the Liverpool inter-agency guidelines on adult protection. The staff receive training around recognising signs of abuse and the procedure to follow when reporting an incident of abuse during the induction. Several staff have also attended further training around adult protection and the manager is making arrangements for the rest of the staff to undertake this training. The staff spoken with had a clear understanding of the adult protection procedure. Residents’ monies are managed by CIC. Their personal allowances are held at the home and the records of this were checked against the monies available and found to tally. Receipts are kept and staff sign records to indicate that money has been received into the home or spent by the resident. As already indicated, residents would benefit from having an advocate or representative Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 17 being involved in the care residents receive and as part of this should be involved in overseeing how residents finances are managed. Salisbury Park (31) DS0000025164.V335428.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, 27 and 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home overall provides a safe, well-maintained environment that meets residents needs and allows them to live in comfortable surroundings. The shower room facilities, do not fully support and safeguard residents. EVIDENCE: The home is a three-bedroom bungalow situated on a small estate of private properties in the Woolton area of Liverpool. The home is generally well decorated and is fitted out in a comfortable domestic style. There is a programme of redecoration. Residents are accommodated in single rooms. There was some damaged furnishings in residents bedrooms which the manager has identified and is in the process of addressing.’ Some of the bedrooms would benefit from further personalisation. Again the manager has identified this and is working with the staff and the residents to address this. Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 19 There are two shower rooms. As already indicated, access to one of these rooms is limited and the main shower room needs to be assessed to enable appropriate aids and adaptations to be made available where needed and with a view to providing more appropriate flooring. At present a small handrail is the only aid available and this may not be appropriately situated. The décor and facilities in the main shower room were poor. It is strongly recommended that a full refurbishment of this room is considered for the comfort of the residents and to match the rest of the property. Residents should have access to a bath as well as showers to enable them to have a choice of how to wash. There was no office available at the home. Records were stored in the hall, in the kitchen and in the lounge in lockable cabinets. The manager reported that supervision takes place in the lounge when residents are accessing the garden. This is not acceptable. Steps should be taken to ensure that the manager has a suitable area for carrying out supervision and other managerial tasks. The home was clean and free from malodour on the day of the visit. Salisbury Park (31) DS0000025164.V335428.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, 35 and 36 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents are safeguarded by the number of staff available. Staff need to have regular supervision to ensure that they are appropriately supported and can in turn appropriately support residents. EVIDENCE: There are usually two members of staff on duty during the day and one waking night staff. A third member of staff is available for some shifts. The staff spoken with said that there are enough staff available to ensure residents take part in activities outside of the home. All 3 staff spoken with were looking forward to the introduction of longer days of work as it will enable a greater range of activities to be introduced. The manager has had one team meeting since being in post and is planning on having these meetings monthly. An induction and foundation training programme is provided to all new staff. The training covers health and safety matters, adult protection, equal opportunities, working with adults with a learning disability and promoting the rights of the resident. The induction and foundation training programmes have been developed in accordance with the National Training Organisation training Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 21 targets. Further training provided to staff in the last 12 months has included the management of challenging behaviour, protection of vulnerable adults, medication management and updating food hygiene and first aid. The staff training records did not appear to contain details of all the training staff have received. The manager reported that she is planning to carry out an audit of all the training staff have received and what they need in the next month. Three of the six staff team have the NVQ level 2 and one is currently undertaking the course. The staff on duty demonstrated a good understanding of the residents’ needs. They were observed spending time with the residents and interacting appropriately. An examination of a sample of staff records indicated that in general the required recruitment information was available. One staff file contained no references. The manager reported that the references have not been sent from the head office of CIC and agreed to address this without delay. An equal opportunities policy is available and it is understood that CIC monitor the effectiveness of this. Policies are available around promoting equality and diversity at the home. The manager reported that training is also being made available to staff around this. The competence of staff to meet the needs of individuals from minority groups should be assessed during the recruitment process. The staff records examined showed that staff are continuing not to have supervision on a regular basis. The manager has only been in post since May 2007 and has taken steps to address this by drawing up a plan of supervision for the next 12 months. It is important that the staff receive regular recorded supervisions to ensure that staff are clear about their roles and aims within the home. Supervision also provides a way of monitoring the staff’s work with residents and provides them with support and professional guidance. Salisbury Park (31) DS0000025164.V335428.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): 37, 39 and 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. There are adequate arrangements for the management of the service, however some improvements are needed to the arrangements for quality assurance so that these systems further benefit residents. EVIDENCE: The current manager has been in post since May 2007. The manager has completed an NVQ level 4 in care and management. The manager has undertaken various training courses to keep her knowledge and skills up to date. The manager is in the process of gathering the information needed to put forward an application to CSCI to be the registered manager for the home. The manager works directly with the residents and is not allocated separate time to carry out her managerial duties. At present the manager reported that Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 23 she attends to records and carries out supervision during quiet periods of the day. As there are usually only two staff on duty, this could result in some attention not being focused on the residents. It is recommended that the manager have allocated time during the week when she is not responsible for supporting residents and can concentrate on her managerial responsibilities. 3 members of staff were spoken with. The staff reported that they consider their views regarding the running of the home are sought and listened to. The staff were very knowledgeable about the needs of the residents. They had a good understanding of the home’s policies and procedures and the general operation of the home. The staff said they like working at the home, they described the manager as “fair and supportive.” They said residents “are well looked after and have a good life.” The service manager visits the home monthly and carries out an audit of residents’ health and welfare, accidents, risk assessments both personal and environmental, staffing levels and other issues. The use of an advocate would assist with the feedback from residents. There is no formal process of obtaining feedback from relatives on how the home operates. Feedback should be obtained from relatives and other stakeholders. It is recommended that questionnaires be used to find out these views, which would allow for the outcomes and the home’s responses to be recorded together with an action plan for future development. As already indicated relatives and social and healthcare professionals are not involved in reviews of the residents care plans. The home has a set of corporate policies and procedures, which are readily accessible to the staff. Training around safe working practices is made available to staff as part of their induction. There is a rolling programme of training opportunities provided and refresher courses are undertaken when needed. There are policies and procedures and risk assessments available that promote safe working practices. A sample of safety/maintenance check certificates and records were examined and in general found to be in order. Certificates showing that the gas and electrical wiring are safe were not available. These are to be forwarded to CSCI. Salisbury Park (31) DS0000025164.V335428.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 X 2 3 3 X 4 3 5 2 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 2 25 X 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 3 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 2 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 3 X 3 X 2 X X 2 X Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 25 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA5 Regulation 17 Requirement The registered persons must ensure that contracts/terms and conditions indicate what residents are responsible for paying for and what is included in the cost of the fees residents/placing authority pay to CIC. The registered persons must ensure that care plans are reviewed in consultation with the resident and their representatives. The registered persons must ensure that behaviour management guidelines provide clear guidance to staff around how staff are to manage behaviours that are challenging. Timescale for action 11/09/07 2. YA6 14 11/09/07 3. YA6 14 11/07/07 4. YA19 23 The registered persons must 11/07/07 take action to ensure that the shower room has the appropriate flooring and aids and adaptations to meet the needs of the residents and to safeguard against any risk of accidents. An occupational therapist needs to DS0000025164.V335428.R01.S.doc Version 5.2 Page 26 Salisbury Park (31) be consulted regarding the aids and adaptations in the bathroom. 5. YA19 15 The registered persons must ensure that epilepsy management guidelines provide clear guidance to staff around how staff are to support residents. The registered person must ensure that recruitment records contain evidence that two appropriate references have been obtained. The registered person must ensure that staff working at the home receive regular supervision. The registered persons are to provide a copy of the safety certificate for the electrical wiring and gas supply to CSCI. 11/06/07 6. YA34 19 11/06/07 7. YA36 18 11/06/07 8. YA42 23 11/07/07 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 YA2 Good Practice Recommendations Further information should be gathered about the lives of the residents before they lived at the home as this will help to inform care planning. It is strongly recommended that an individual independent of the home agree that the contract/statement of terms and conditions meets the interests of the residents in accordance with their wishes and abilities. 2. YA5 Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 27 3. YA7 It is recommended that the residents have access to a local advocacy service to assist them with making independent decisions. It is recommended that the communication guidelines be further developed with the assistance of a speech and language therapist. Steps should be taken to ensure that the manager has a suitable area for carrying out supervision and other managerial tasks. It is strongly recommended that a full refurbishment of the bathroom and toilet is considered for the comfort of the residents and to match the rest of the property. Residents should have access to a bath as well as showers to enable them to have a choice of how to wash. The competence of staff to meet the needs of individuals from minority groups should be assessed during the recruitment process. It is recommended that the manager have allocated time during the week when she is not responsible for supporting residents and can concentrate on her managerial responsibilities. It is recommended that questionnaires be used to find out the views of parents and other stakeholders about the operation of the service. 4. YA7 5. YA24 6. YA27 7. 8. YA27 YA34 9. YA39 10. YA39 Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 28 Commission for Social Care Inspection Merseyside Area 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. Extracts may not be used or reproduced without the express permission of CSCI Salisbury Park (31) DS0000025164.V335428.R01.S.doc Version 5.2 Page 29 - 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. 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