Inspection on 12/01/07 for Salisbury Terrace (12)

This inspection was carried out on 12th January 2007.

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

The inspector found no outstanding requirements from the previous inspection report, but made 6 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) 10/03/06

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 Debbie Corcoran Key Unannounced Inspection 12th January 2007 10:30 Salisbury Terrace (12) DS0000025161.V307479.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 Terrace (12) DS0000025161.V307479.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 Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 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.V307479.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 10th March 2006 Brief Description of the Service: 12 Salisbury Terrace is a small home registered to provide care for up to three people with a learning disability. The service is provided by Autism Initiatives and the registered Landlord for the property is Liverpool Housing Trust. Autism Initiatives was formerly called the Liverpool and Lancashire Autistic Society and it was established in 1971. The organisation provides a variety of services to adults and children who have autism. These include residential care, day care, supported tenancies, outreach, domiciliary care, respite and educational services. Autism Initiatives is a voluntary organisation with charitable status. 12 Salisbury Terrace is a four bedroom house which is located in a residential area in Wavertree, Merseyside. The home is a domestic property which promotes the principles of ordinary community living. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit to the home was not announced beforehand. During the visit one of the service users was met. During a return visit to the home the other two service users were met. The home manager and a small number of members of the staff team were spoken with. Service user plans, staff training records, health and safety records and other relevant records were examined in some detail. A tour of the home was carried out which included all areas. The manager returned a questionnaire on the service to the Commission and some of the information in this has also been used to inform the findings of this inspection. What the service does well: What has improved since the last inspection? Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 Page 6 Staff described how some of the service users are having the opportunity of trying different leisure activities. Staff have been provided with further training since the last inspection. There have been some improvements to the presentation of the home and some redecoration. 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.V307479.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 Terrace (12) DS0000025161.V307479.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. This standard could not be practically assessed, however it was noted that systems are in place for ensuring the needs of prospective service users are assessed before they move to the home. EVIDENCE: There have been no new service users to the home for many years and therefore the assessment and referrals processes could not be practically assessed. Autism Initiatives do have assessment and referral policies and procedures to be used when a new service user is referred to the home. These detail that an assessment of the prospective service user’s needs is carried out prior to the person moving in to the home. The assessment format is good and includes areas for information which are specific to the needs of people who have autism. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 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, 9 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Each of the service users has a plan of care which provides information on their needs. Care plans are not reviewed regularly and may therefore not reflect changes to the service use’s needs. Staff are aware of potential risks to service users and support the service users accordingly. EVIDENCE: Each of the service users has a support plan which describes how to support the person with developing aspects of their independent living skills. Further information is included in the service users records as to how to support the service users with their personal care, physical care, health care and emotional and psychological needs. There was no evidence that support plans and other care planning information is being reviewed as the information did not include signatures, dates or evidence to show that the information has been reviewed or updated. Care planning information describes the service users preferences and daily routines and service users are encouraged and supported to make their own Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 Page 10 decisions and to participate in the decision making in the home. During discussions with a member of staff they were able to give examples of how they encourage the service users to make as many choices as possible and to use and develop their independent living skills. Risk assessments are carried out for each of the service users. These identify potential hazards to the service users safety and well being and include detailed guidelines as to how to then manage the risk or prevent the risk from occurring. The risk assessments cover different aspects of the persons support. For example support with communication and community access. The risk assessments are comprehensive and are reviewed regularly. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 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): 12, 13,14, 15, 16, 17 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are supported to develop their independent living skills. Service users are not involved in a great variety of leisure activities or community access. Service users are offered a good choice of healthy food and staff are aware of the service needs with their diet and eating. EVIDENCE: Service user’s care plans included some information on their personal care skills and needs and a member of staff gave some examples of how they support the service users with developing their personal and independent living skills. Daily records regarding the service users care and support are maintained. These were examined to assess the frequency of leisure opportunities and community access for two of the service users over the past 6 weeks. These records indicated that the service users are not supported to be involved in activities on a regular basis and there are occasions when the service users Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 Page 12 might not go out for a relatively long period of time. The records also indicate that the service users aren’t being offered a great variety of activities with the vast majority of outings being for shopping purposes. The manager must review the current needs of the service users with regards to community access and leisure and show that there has been planning in to how to best meet the needs of each of the service users. Service user’s records include information on the people who are important to the service user and contact details for relatives, friends and relevant others. In assessing the diet and meals available to service users menu records were looked at and the availability and storage of food was checked. These indicated that service users have a good choice and variety of food and meals. The kitchen was checked and found to be well stocked with food and snacks and facilities for service users to make hot and cold drinks. Service users are supported to do the shopping for the home and are encouraged to use and develop their skills in preparing and cooking food as appropriate to their needs. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 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, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users are well supported with their health and physical care needs and with their emotional well-being. EVIDENCE: Service user’s records include guidelines for supporting the service user with their health care needs and with their personal care needs. This includes a good level of information on the individual’s likes and dislikes and preferred routines and information for staff on how to support the service users with their emotional well-being. Records showed that service users are supported to attend regular health checks and arrangements are made for service users to see a GP or district nurse as required. Policies and procedures are in place for the receipt, storage, administration and disposal of medications. There were no medications at the home and therefore the implementation of these procedures could not be practically assessed. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Policies, procedures and practices are in place for dealing with complaints and for aiming to protect service users against abuse or neglect and systems are in place for dealing with allegations of abuse. EVIDENCE: The home has a complaints procedure which is time scaled appropriately. There have been no complaints to the home since the last inspection. The home has a protection of service users policy and an abuse policy. The majority of staff have been provided with training on the protection of vulnerable adults. Staff who were asked about how they would respond to an allegation of abuse were able to provide appropriate answers. The home has further policies and procedures aimed at protecting service users including a policy and procedure on the management of service user’s money. However, service users are requested to pay members of staff for travel purposes if they use the staff’s own transport. This agreement is not formalised in a policy and procedure and not formally audited to ensure that service users and staff are not left in a vulnerable position. The manager should also introduce a system for regularly auditing service user’s monies and for staff to account for checks of this. A record of key events is maintained for example incident reports and accident reports. These were checked and found to be maintained appropriately and there were no areas of concern identified. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 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, 30 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home is clean and safe and generally presented to a satisfactory standard although there is room for improvement in a number of areas. EVIDENCE: A tour of the premises was carried out which included all areas. The home is an ordinary domestic property. There is one communal lounge and each of the service users has their own bedroom. Two of these were viewed and found to be adequately presented. The tour of the home revealed that a number of areas require attention; The lounge is in need of redecoration. Carpeting in the hallway and lounge needs to be replaced as it is stained and has not improved with cleaning. A suitable lock must be fitted to the bathroom door. As the last inspection it was recommended that the shower room is relocated from the ground floor to the first floor 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. It was reported that the shower has been replaced since the last inspection. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 Page 16 The home has health and safety practices and procedures which are aimed at ensuring the home is safe and clean and as free from hazards to the health and safety of service users and staff. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 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, 33, 34, 35 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. Service users are supported by appropriately trained and qualified staff. A lack of information on staff recruitment and selection means that the manager is not able to evidence that service users are protected through appropriate and thorough staff recruitment and selection practices. EVIDENCE: Staff within the home and across the organisation have clear roles and responsibilities. Staff are provided with training as appropriate to meet the needs of the service users. Staff training includes training on topics such as first aid, fire safety, adult protection, moving and handling, infection control and supporting people who have autism. All members of staff on the team have attained a National Vocational Qualification (N.V.Q) in care. The staff team is fairly stable. There has been only one new member of staff since the last inspection. The recruitment and selection procedures used when employing this member of staff could not be assessed as the appropriate records were not available at the home. Autism Initiatives as an organisation hold this information centrally. Where this is the case there should be a signed and dated checklist / statement confirming that pre employment checks have been carried out. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 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, 39, 41, 42 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to the service. The home does not have a manager who is registered with the Commission. The home is run in the best interests of the service users. However there are some areas for improvement. Procedures, practices and checks are in place which aim to safeguard and protect the health and safety and well being of service users and staff. EVIDENCE: The home has a new designated manager. This person has worked for Autism Initiatives for approximately 8 years. The manager must make an application for registration with the Commission. There is a quality assurance process at the home which includes regular visits and audits from a representative employed by Autism Initiatives. Quality assurance also includes seeking the views of service users and staff as to the quality of the service provided. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 Page 19 The manager should ensure that recorded staff meetings occur more frequently. This is to ensure that staff members have a regular forum to discuss issues that may effect the service provided to service users and the implementation of polices, procedures and practices within the home. Staff are provided with training in health and safety topics and the home has health and safety policies and procedures. Fire safety and health and safety practices are adopted. Records of fire and health and safety checks were checked and found to be up to date. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 Page 20 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 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 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 3 32 3 33 2 34 2 35 3 36 x CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 x 3 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 x 3 x x x x Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? No STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard YA37 Regulation 8 Requirement The registered person shall ensure that an application for the registration of manager is made to the Commission. The registered person must ensure that service user’s care plans are reviewed regularly. The registered person must review the opportunities for activities and community access provided to service users to ensure that these are meeting the service users needs and promoting their well-being. The registered person shall ensure that a policy and procedure is in place regarding money paid by service users to staff for any purposes. The registered person shall ensure all repairs and maintenance work as identified in the report are completed. This includes redecoration of the lounge, new carpeting to the hall and lounge and a lock to be fitted to the bathroom door The registered person must DS0000025161.V307479.R01.S.doc Timescale for action 12/03/07 2. 3. YA6 YA13 15 (2) (b) 16 (2) (m) 12/03/07 12/03/07 4. YA23 13 (6) 12/04/07 5. YA24 23 12/05/07 6. YA34 17 (2) 12/03/07 Version 5.2 Page 22 Salisbury Terrace (12) schedule 2 ensure that appropriate evidence of the staff recruitment and selection procedures are available at the home. 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 YA23 YA27 YA33 Good Practice Recommendations The registered person should ensure that service user’s monies are regularly audited and balance checks are carried out and recorded on a regular basis. It is recommended that the shower room is relocated from the ground floor to the first floor as this would provide a higher standard of privacy to the residents. 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. Salisbury Terrace (12) DS0000025161.V307479.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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. 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