Inspection on 10/03/06 for Salisbury Terrace (12)

This inspection was carried out on 10th March 2006.

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

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Salisbury Terrace (12) 05/09/07

Salisbury Terrace (12) 12/01/07

Salisbury Terrace (12) 15/12/05

Salisbury Terrace (12) 19/03/05

Salisbury Terrace (12) 19/05/04

Salisbury Terrace (12) 04/02/04

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 Terrace (12) 12 Salisbury Terrace Wavertree Liverpool Merseyside L15 4HD Lead Inspector Karen Barry Announced Inspection 10th March 2006 09:30 Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Salisbury Terrace (12) Address 12 Salisbury Terrace Wavertree Liverpool Merseyside L15 4HD 0151 735 0283 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) salisbury@autisminitiatives.org www.peterhouseschool.org Autism Initiatives Mr Christopher Dullaghan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 15th December 2005 Brief Description of the Service: 12 Salisbury Terrace is a Victorian three story mid-terrace property, with a large rear garden. The property is owned and maintained by Liverpool Housing Trust (L.H.T.) The house is the home of three residents with Aspergers Syndrome and is managed by Autism Initiatives. The accommodation comprises of a communal kitchen, bathroom, shower room and living room shared by service users and staff. Each resident has their own single room decorated according to their individual taste, all three bedrooms have displayed items of the individual residents personal memorabilia. There is an office/sleep-in room on the top floor. Residents are supported and encouraged to fully access all local facilities and amenities, including college courses, sport centres and local pubs. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Prior to the inspector undertaking this announced inspection the Manager and the residents had been asked to provide the inspector with written feedback in relation to a number of areas that where assessed against National Minimum standards for Adult Care Homes. On the day of the inspection only one resident was at home the other two where undertaking planned activities within the community as set out within the care and support plans. The inspector discussed a range of working practices with the various staff members that where on duty and examined a variety of records that related to the services provided. Observations of interactions between the resident and the staff where also undertaken whilst touring the home and chatting with staff members. During discussion with staff members it was highlighted that the completion of residents comment cards had been a difficult experience, as the format presently used by the Commission doesn’t appear to fully take into account the differing communication needs of the residents within this home. What the service does well: The home provides specialist services and where necessary one to one support for residents in and outside the home. The house appears well equipped and fits unobtrusively into the local neighbourhood Resident care files are structured and clearly written. Care & support plans used within Salisbury Terrace clearly respect residents rights and the need to promote independence and choice. Residents appear happy and indicated that they were satisfied with the care and support they received. Staff members spoke positively about the home and the organisation the work for. They all appeared very committed to supporting the residents to exercise choice and control over their lives, whilst maintaining contact with relatives and the local community in which they now live. The staff members the inspector met clearly demonstrate their commitment to advocating on the residents behalf as and when it was deemed necessary. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 6 What has improved since the last inspection? 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. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: Not assessed on this occasion as the residents have been living within the home for a number of years and it is not envisaged that there will be an opportunities for any other residents to be admitted at this time. It appear that Autism Initiatives and the staff within Salisbury Terrace ensures prospective residents are always provided with information in suitable formats to enable them to make an informed decision about the suitability of any of their services to meet assessed needs and aspirations. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,8,9 and 10 Well-written detailed care & support plans remain in place, enabling residents to make decision and achieve the personal targets set. EVIDENCE: The inspector examined all three residents files, documentation seen confirmed how care and support plans had been updated to take into account issues / concerns encountered alongside actual achievements made by the individual residents. One resident has been working towards purchasing his own newspaper at the local shop. Support plans seen confirmed how various steps and targets have been introduced and reviewed to enable the resident and staff team to clearly understand how and why progress has or hasn’t been made at any given time. Although there are a number of clearly written support plans displayed within various parts of the home to enable residents to complete certain tasks independently the inspector noted that as and when necessary staff members Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 10 did supervised the tasks being undertaken in an unobtrusive manner and that if necessary reassurance was given to reduce anxieties being raised by the resident and how on completion praise was given. The inspector was made aware of how the residents & staff also use pictures as prompts to ensure communication has been explained and understood correctly. Risk assessments and management strategies devised through multidisciplinary planning where seen when examining care files for all three residents. The information recorded within this form of documentation clearly shows how careful consideration has been given to enabling residents to explore a variety of life experiences without any undue stress or injury being incurred. All records relating to residents was seen to be stored securely within the home office ensuring they could have confidence that information held and recorded would not be made available to un authorised personal. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 13,14,15,16 & 17 Participation within the local community is actively encouraged to ensure independence and life experiences are promoted. Residents are assisted in maintaining relationships with their families and friends by staff within the home in accordance with the individuals expressed wishes. Residents are encouraged to maintain a varied health diet. EVIDENCE: Opportunities for personal development where seen to be paramount within care and support plans examined during the inspection. Documentation confirmed residents continue to be involved in various daily living tasks within the house these include tidying of bedrooms, sorting laundry and shopping for meals and clothing as necessary. Records relating to staff and house meetings where available for inspection and these confirm that relevant actions are under taken to ensure the home runs in the best of the residents Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 12 and that suitable activities are agreed to enhance the residents participation within the local community. It was noted that daily and weekly activity plans are traditionally fixed to take into account the residents needs to avoid unnecessary changes to their daily routines. Activities offered include visits to local pubs and restaurants, the local sports centre, day centres /colleges and community farm. Residents are given the opportunity to choose an annual holiday where they are supported and accompanied by staff, as well as having the opportunity to spend various amounts of time away from the home with members of their own families. All three residents are reported to have enjoyed recent opportunities of spending Christmas with their individual families. Menus have been devised taking into account the preferences of the residents. Daily meal choices are often made by the use of pictures to ensure each of the residents fully understands what they are being offered. Meals are prepared and cooked by the staff members on duty. Residents are involved in purchasing the weekly shopping with the staff as this enables them to consider other options that may need adding to their menus at a later date. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18 & 19 Residents are encouraged to maintain their independence with regards to their personal care. Resident’s physical emotional and healthcare needs are met appropriately by the assistance and support from a staff group who have a wealth of knowledge and experience of their individual needs. EVIDENCE: The residents within Salisbury house continue to require minimal assistance when undertaking personal care tasks. This normally consists of verbal prompts from staff members, however presently written care and support plans have been used to prompt and guide individual residents to completing tasks independently without constant supervision. All three residents are registered with a local GP and they have access to various health care services as required. None of the residents are presently prescribed any medication. Records seen indicated that staff members encourage six monthly check ups at the dentist, annual check ups at the well mans clinic and a two yearly appointments at the opticians. In order to ensure each of the residents receives appropriate advice and any treatment required to remain as healthy as possible. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 Accessible polices and procedures are in place to safe guard residents. Staff appear to have sufficient knowledge and insight regarding their roles and responsibilities to protect the service users from abuse and neglect. EVIDENCE: The organisation’s complaints procedure has been produced in two booklets referred to as the “who to Talk to” and “what to do” These are designed to assist residents and their representatives to express their views and any issues/concerns, ensuring they are heard and acted upon in an appropriate manner. Within Salisbury House bullet points and pictures have been used and displayed to enable residents to make reference to what to do if they ever felt unhappy with events or staff within the home. Staff members within Salisbury terrace have all received training in recognising and reporting any issues of abuse self harm and neglect, and are all in the process of receiving an update in this area to ensure they are fully aware of their roles and responsibilities in ensuring residents always receive appropriate levels of protection. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,26,27 & 28 Residents have access to private and communal areas within the house, which are clean, comfortable and homely. EVIDENCE: Communal space is homely and comfortable, and the general layout of the home is fully accessible by the residents presently living within the house. The kitchen was found to be clean, tidy and sufficiently stocked with fresh and frozen food supplies. Open food supplies stored with the fridge where found to covered / wrapped and where necessary dates of opening foods had been recorded. A jar of mayonnaise was noted to be out of date staff removed and disposed of this in the inspector’s presence. The inspector was informed that there a number of the rooms within the house have been redecorated and that a new dryer had been purchased to replace the previous one that had broken down. Maintenance and visitor books indicated that issues relating to ongoing plumping problems within the house have been addressed quickly and affectively. It was reported that the toilet within the main bathroom had been Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 16 rather problematic of late and that recently decorated areas of the home had had to be re done to remove the new water marks that had been caused. It was noted that the lounge and hallway carpets haven’t been replaced as discussed during the previous inspection. The manager and staff members were informed that a recommendation would be made to ensure this work was undertaken in the very near as there are a number of stains appearing which they report can’t be removed and this is spoiling the overall appearance of the home. Residents bedrooms viewed confirmed that they had been personalised to reflect their individual personalises and lifestyles. One of the residents’ rooms has been decorated since the last inspection; this resident is reported to be very pleased with the new colour and appearance. The inspector was informed that due consideration is being given to the recommendation made in the last report regarding the moving the shower room to the first floor. It’s hoped that this work will continue as it would provide a higher standard of privacy to the residents and could reduce the need for continuous repair and maintenance work being undertaken in the smaller room presently in used upon the ground floor. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32 & 34 Residents appear to benefit from a good skill mix of suitably qualified and experienced staff members, who strive to provide a consistent approach to the care and support provided. EVIDENCE: Staff members spoken to demonstrated a clear understanding of their individual and group roles and responsibilities not only within Salisbury house but as employees of Autism Initiatives. They confirmed that they have regular access to new and refresher training opportunities, to assist them in undertaking their duties. Information received within the pre questionnaire confirmed that all staff members are in receipt of National Vocational Qualification (NVQ) to level 2 or above. The inspector was shown documentation to confirm that staff members employed within the home have undergone necessary Enhanced Criminal Record Bureau checks. However a full examination of selection and recruitment procedures was not deemed necessary as no new members of staff have been employed to work within this home for almost 5 years. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 18 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38,39,40, 41 & 42 The health, safety and welfare of both residents and staff appears to be promoted and safe guarded. Residents and staff within Salisbury Terrace appear to benefit from an experienced and organised manager. EVIDENCE: Observations and discussion with staff members demonstrated that the registered managers leadership style ensures the home is run in the best interests of the residents. However the registered manager has recently been given an opportunity to expend his knowledge and experience within the organisation this has resulted in his working hours within the home being reduced to just two days per week on a temporary basis. Suitable arrangements have been made for the deputy manager to assist more formally with the day to day running of the home during his absence. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 19 The inspector believes that such arrangement are satisfactory on a short term basis however the registered person is required to keep CSCI up dated with any further developments and that if this temporary arrangement exceeds a six month period that due consideration is given to the longer term implications of the management of the home. Staff spoken with during the inspection confirmed that they were happy and comfortable with the way in which the home was being managed and although communicating directly with the residents was difficult for the inspector observations of body language and interactions indicated that he and the other residents were happy living in the home and that they had developed good working relationships with the staff team. The home appears to benefit from a open and proactive ethos. Observations indicate that staff and residents are encouraged to be involved and informed about all aspects of the management of the home. Discussions confirmed that suggestions where listened to an acted upon if it had been agreed the benefits for the residents would be achieved. Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 20 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 X 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 3 26 3 27 3 28 3 29 X 30 X STAFFING Standard No Score 31 3 32 3 33 X 34 3 35 X 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 X 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X X 3 3 3 3 3 3 3 Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 21 no 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 YA37 Regulation 8&9 Requirement The registered person must ensure CSCI is kept up to date with on going management arrangement within the home and to ensure due consideration is given to the longer term implications of the registered manager’s reduced hours extending past further than a six month period. Timescale for action 30/05/06 Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA41 Good Practice Recommendations The registered manager should ensure that recorded staff meetings occur more frequently to ensure staff members have a regular forum to discuss issues concerns events that may effect the implementation of relevant polices and procedures used within the home. It is strongly recommended that work presently being undertaken with regards to considering the proposal to move the shower room from the ground floor to the first floor continues, as this would provide a higher standard of privacy to the residents and could reduce the need for continuous repair and maintenance work being undertaken in the smaller room presently used. It is strongly recommended that the lounge and hall carpets are replaced as a number of stains cannot be removed and this is spoiling the overall appearance of the communal areas. 2 YA27 3 YA24 Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 23 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Salisbury Terrace (12) DS0000025161.V268631.R01.S.doc Version 5.1 Page 24 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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