Inspection on 15/12/05 for Salisbury Terrace (12)

This inspection was carried out on 15th December 2005.

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) 10/03/06

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 Unannounced Inspection 15th December 2005 10:30 Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 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.V272532.R02.S.doc Version 5.0 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.V272532.R02.S.doc Version 5.0 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 Autism Initiatives Mr Christopher Dullaghan Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 19th March 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.V272532.R02.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The staff at the home had not been told that the inspection would be taking place prior to the inspectors arriving. On this occasion Dave O’Connor Regulation Manager accompanied the lead inspector, as part of the Commission for Social Care and Inspection’s (CSCI) staff developmental programme. The inspection took place over 4 hours and included the viewing of records a tour of the house and discussion with residents and staff members. What the service does well: What has improved since the last inspection? What they could do better: Care/support plans are in place to assist residents in pursuing individual interests through college courses. A proactive approach to pursuing supported Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 6 employment opportunities could enhance the resident’s present and future lifestyles. In order to provide a higher standard of privacy to residents when undertaking personal care tasks consideration should be given to moving the shower room from the ground floor to the first floor where more space and discretion could be achieved. 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.V272532.R02.S.doc Version 5.0 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.V272532.R02.S.doc Version 5.0 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): 2,3 & 5 Suitable policies and procedures are in place to ensure residents and staff members would give and receive appropriate information before making any decisions regarding the choice of home for prospective residents. EVIDENCE: All three residents where admitted to the care home a number of years ago. Evidence was seen to confirm that their admissions had only taken place after a multidisciplinary assessment and care-planning process had been completed. This supports evidence that all concerned felt confident that the home and its staff could adequately meet identified needs and aspirations. Individual signed contracts for each resident where seen with the care files examined. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 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 Well written care/support plans and risk assessments are in place, which encourage decision-making and assist in achieving personal targets set. EVIDENCE: All three residents files seen confirmed that appropriate plans where in place and that these where reviewed on a regular basis. It was noted that a number of changes to documentation used are in the process of being completed. It is recommended that when this has been completed that previous or out of date paperwork used be archived to prevent confusion regarding the individual residents current situation. Care/support plans where seen within various rooms of the house. The manager and the staff explained these serve as prompts to assist residents in completing various daily living tasks in a safe and independent manner. Information recorded upon file copies of care/support plans confirm that these are reviewed at regular intervals to show how and when targets are achieved. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 10 Records seen shows that staff members ensure these reviews are dated and signed appropriately. Risk assessments and management strategies devised through multidisciplinary planning where seen when examining care files for all three residents. Through discussion the registered manager was able to confirm that as and when necessary advice and guidance would be sought from appropriate health and social care professionals should the risk management strategies become ineffective or indeed if new risk where identified. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 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): 11,12,13,14,15 & 16 Support to maximise opportunities for personal development, independence and maintaining key family relationships was evident from observations made and through discussion with the staff members. EVIDENCE: The core element of all the residents care/support plans seen indicated that opportunities for personal development where paramount. Records, discussion with staff and observations of the day’s events confirmed that residents attend college courses and a range of social and leisure activities, to assist them in developing and maintaining new skills and levels of ability. One of the residents went out swimming shortly after we arrived and then went on to a local day centre. Another residents declined to go swimming as previously arranged, staff members respected his decision to change his mind. It would appear that our presence and the fact that work was being undertaken re fitting new carpets in the house had led to his change of mind. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 12 Staff members clarified that they need to be extra vigilant to the residents behaviour when changes occur as some residents find it extremely unsettling if things are altered without clear explanation, preparation and planning. Residents are involved in various daily living tasks within the house this includes tidying of bedrooms, sorting laundry and shopping for meals and clothing as necessary. Residents are supported by staff members to undertake a range of activities within the local community these include visits to local pubs and restaurants, visits to the local sports centre, college 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. The registered manager informed the inspectors that all three residents where going home to spend Christmas with their families. He confirmed management strategies where in place for family members to access support and guidance from staff members should any difficulties arise. Observations of staff interactions with residents confirmed that they respected the resident’s rights to privacy. They also demonstrated that they had all acquired a great of knowledge and understanding of the resident’s individual abilities and the affect this can have upon their daily lives and aspirations. Staff encourage residents to be involved in decisions made regarding the support and services they are offered and receive. The inspector was told that one of the residents regularly attends service user meetings held by Autism initiatives, this ensures the corporate management gain a full understanding of how all of their services are viewed by residents and users of their various services. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 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 &21 Staff members have a wealth of knowledge and experience of working within Salisbury Terrace and appear to have formed good relationships with the residents to ensure they receive the right levels of support and assistance to meet their needs. EVIDENCE: The residents within Salisbury Terrace require minimal assistance when undertaking personal care tasks. This normally consists of verbal prompts from staff members, however presently written care/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 have access to various health care services as required. None of the residents are presently prescribed any medication. Records seen indicated that six monthly check ups where undertaken at the dentist, annual check ups at the well mans clinic and two yearly appointments where made at the opticians. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 14 A policy is in place with regards to death of a residents and its was reported within a previous inspection report that a member of staff has had an opportunity to attend a bereavement course. Information relating to the individual resident’s and their families wishes regarding funeral arrangements was seen within care files. This ensures staff members are able to carry out their wishes. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 15 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 The use of graphics contributes to the complaints procedure being accessible to the residents. Polices and procedures are in place to safe guard residents. EVIDENCE: Residents indicated that staff where aware of their views and acted upon these when necessary. No complaints have been received at the home or CSCI office since the previous inspection. A copy of the policy and procedure regarding the protection of vulnerable adults was in place within the house office and it has previously been recorded that the registered manager has had the opportunity to attend interagency adult protection seminars to enhance his knowledge in this area. All staff members undertake in house adult protection training. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 16 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 & 30 Salisbury Terrace appears clean, tidy and well presented. Residents have access to private and communal areas within the house, which is 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. The small shower room upon the ground floor was found to be clean and tidy, however it is recommended that some of the tiling is resealed and that the use of mildew spray is used after every use to prevent a build up of mildew / mould, which could lead to an unhygienic environment. The registered manager informed the inspectors that a request to move the shower room from the ground floor to the first floor had been made to LHT recently. It is recommended that carefully consideration is given to this request as such a move could provide a higher standard of privacy to the Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 17 residents and could reduce the need for the continuous repair and maintenance work that has regularly been required. New carpets where fitted to the residents bedrooms, on the day of the inspection. It is envisaged that the lounge and hallway carpets will be replaced in the near future as a number of stains that can’t be removed are spoiling the appearance. Arrangements have been made to decorate one of the resident’s bedrooms next week. Staff confirmed that the resident has been involved in choosing the colours to be used, however they indicated that they are unsure how this will look when complete as they had been informed that this redecoration would involve painting over the present wallpaper. Residents’ bedrooms viewed confirmed that they had been personalised to reflect their individual personalises and lifestyles. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 18 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): This area was not formally assessed during this inspection as access to staff files was not available. However, it is worth noting that the staff group has remained stable for a number of years. Discussion with the registered manger indicates he is aware of procedures that need to be followed. EVIDENCE: Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 19 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 Residents and staff within Salisbury Terrace appear to benefit from an experienced and organised manager, who ensures the health, safety and welfare of both residents and staff, is promoted and safe guarded. 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. The registered manager is hoping to complete his National Vocational Qualification (NVQ) at level 4 during 2006. 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 was agreed benefits for the Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 20 residents would be achieved. Records of staff meeting where seen during the inspection to confirm information received in discussion. The service manager makes regular visits to the home and records findings and outcomes upon regulation 26 forms, which are forwarded to CSCI local office at regular intervals. Autism Initiatives has achieved the Investors in People award and undertakes routine Quality Assurance audits, in order to gain the levels of satisfaction from the residents and their families regarding services offered and received. Records viewed throughout the inspection where found to be organised and accurate. Various polices and procedures where available for inspection and are accessible to staff members at all times so that they can refresh their knowledge and practice if and when the need arises. Records show that the fire alarm system is tested on a weekly basis, with a full evacuation taking place. Insurance, service and maintenance records viewed where valid and up to date. However it was reported that there have been occasions when work has been completed and no certificate has been produced until the registered manager has made contact with either LHT, Autism Initiatives head office or the service people direct. During these discussions it was noted that the home did not have any faxing facilities, which is a requirement under regulation 16 of The Care Home Regulations 2001. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 Page 21 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X 3 3 X 3 Standard No 22 23 Score 3 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 3 3 X Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 X X 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X X X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Salisbury Terrace (12) Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 3 3 DS0000025161.V272532.R02.S.doc Version 5.0 Page 22 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 OP37 Regulation Reg 16 (aii) Requirement The registered person must ensure that the home has appropriate facilities for communicating by facsimile transmission. Timescale for action 01/02/05 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 OP21 Good Practice Recommendations It is strongly recommended that due consideration be given to the recent proposal made for moving the shower room from the ground floor to the first floor. 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. Salisbury Terrace (12) DS0000025161.V272532.R02.S.doc Version 5.0 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.V272532.R02.S.doc Version 5.0 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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