Inspection on 19/06/07 for Sefton Street, 132

This inspection was carried out on 19th June 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Sefton Street, 132 27/09/06

Sefton Street, 132 02/03/06

Sefton Street, 132 24/10/05

Sefton Street, 132 31/01/05

Sefton Street, 132 18/08/04

Sefton Street, 132 11/03/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Sefton Street, 132 132 Sefton Street Southport Merseyside PR8 5DB Lead Inspector Mrs Janet Marshall Key Unannounced Inspection 19th June 2007 09:30 Sefton Street, 132 DS0000005227.V334647.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 Sefton Street, 132 DS0000005227.V334647.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. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Sefton Street, 132 Address 132 Sefton Street Southport Merseyside PR8 5DB 01704 530329 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) www.peterhouseschool.org Autism Initiatives Stephen Halewood Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 3 LD Date of last inspection 27th September 2006 Brief Description of the Service: 132 Sefton Street is an older, semi-detached property providing care and accommodation for three adults with learning disabilities, specifically with Autism. It is situated in a residential area of Southport, close to public transport and the amenities that the town has to offer. The home provides accommodation over two floors with the service users’ individual bedrooms situated on the first floor. There are two bathrooms for service users to share with one including a shower facility. The communal space includes a large dining/kitchen area and a lounge. The home has a pleasant rear garden including decked area including garden furniture suitable for service users and their visitors. This is easily accessed. The home is part of a Voluntary Organisation known as Autism Initiatives. It cost £1073.31 – £1418.47 per week to live at the home. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection. The Commission considers 22 standards for Care Homes Adults as Key Standards, which have to be inspected during a Key Inspection. The report has been put together using information gathered from a number of sources including information that the commission have received about the service since the last inspection and details provided in the pre-inspection questionnaire. “Have your say” Surveys were sent out by the Commission to people before the inspection, however none of them were completed. A site visit to the home was also carried out as part of the inspection. Records examined, people’s comments and observations made during the visit have also been used as evidence for the report. The site visit was unannounced and took place over one day for a total of six hours. The inspection was conducted with the manager who was on duty at the time. People spoken with during the visit, included a resident, the manager and a number of staff. It was not possible to obtain the views of other residents because of the nature of their disability however case tracking and observations made during the inspection visit enabled the inspector to get an idea of what is like for the people to live at the home and how their needs are being met. The requirements and recommendations given as part of the last inspection report were discussed and checked with the manager. What the service does well: Available at the home were a number of policies and procedures, which aim to ensure that people make a positive choice about living there. The manager showed a good understanding of the companies needs assessment document and was able to describe in good detail the areas it covers. Support plans and guidelines were in place for each person. The documents clearly set out how staff need to support the persons health, personal, and social care needs. The plans put a lot of emphasis on personal development and show that people are given appropriate opportunities to learn and use practical life skills. During the inspection visit staff were observed treating residents with respect. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 6 Residents are encouraged and appropriately supported to take part in routines of the home. Staff are particularly good at ensuring that the right assistance is given to people with communication difficulties enabling them to make every day choices and decisions. The home has in place appropriate written procedures for responding to concerns and complaints and for ensuring that residents are safe from abuse, harm or neglect. The procedures for complaining and reporting abuse are also available in picture format with symbols so that people that have difficulties reading can easily understand it. The commission have not received any complaints about the home since the last inspection. More than half of the staff team have achieved or are working towards a National Vocational Qualification in Care level 2 and above. Staff are involved in an ongoing programme of training, which is relevant to the work that they carry out. Staff spoken with showed a real commitment to their work. They were knowledgeable about the residents and had a good level of understanding about Autism, the effects it has on peoples lives and how to support them positively. The manager runs the home well. Records were well kept up to date and accurate safeguarding the best interests of the residents. Since the last inspection he has made a number of improvements to the home, which benefit both residents and staff. What has improved since the last inspection? At the last inspection original assessment documentation for a number of residents was not available at the home. The manager explained that this is due to the length of time that they have lived at the home. However detailed assessment of needs, which have been carried out for each person as part of the new support planning process were available in each persons care file. These showed that the home is meeting each persons needs. A policy for admitting new residents to the home has been made available since the last inspection. The policy details processes such as assessing needs, introductory and trial visits, which help the person, make the right choice about living at the home. The manager has followed through his intention to discuss with residents GPs the provision of homely remedies to residents. He has obtained the relevant information, which was needed to ensure that resident’s health, safety and welfare are not compromised. The auditing system put in place by the manager are now being signed and dated to show that the information if relevant and up to date. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 7 During the previous inspection the manager had identified that one resident had become more involved in handling food and felt that this resident would benefit from food hygiene training. Since the last inspection the resident has attended the training, a certificate, which was seen, showed his achievement. Details of all fire drills are now recorded ensuring that events take place and at the required intervals. Since the last inspection the manager has consulted with the fire authority about fire safety issues, which had the potential to put residents at risk. Following a visit to the home the fire authority provided in writing a number of recommendations which have been fully actioned by the manager minimising the risks. 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. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2&5 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed assessments are carried out prior to and following admission of a new resident so that they can be sure that their needs will be met at the home. Each resident has a contract to show that they agree to the terms and conditions of their occupancy. EVIDENCE: There have been no new residents admitted to the home since the last inspection. Procedures were available at the home to show that new residents are admitted only on the basis of a full assessment undertaken by the home and other relevant professionals. The manager was able to clearly describe the company’s procedures for admitting a new resident to the home and said that he would be fully involved in this process. Assessment information was available for one resident that was admitted to the home approximately two years ago. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 10 Assessments carried out by Autism initiatives and a social worker covered aspects of the person’s life such as communication, behaviour management, health and personal care, risk management and future goals. Assessments for the other residents were unavailable due to the length of time that they have lived at the home. The manager confirmed that ongoing assessments are carried out for all three men to ensure that their needs can be met at the home. Records, which were viewed, evidenced this. Before support plans are put in place a full and comprehensive assessment of needs is carried out with the involvement of the resident, manager and practice support team. The manager explained that the assessments are the basis for each support plan. A requirement was made as part of the last inspection, which stated that all residents must receive contracts in an appropriate format and that they must be signed and dated on behalf of the resident by an independent person. At this inspection completed contracts of residency were seen for each of the residents. The manager explained that were appropriate he is working towards providing them in a format, which can be better understood by the residents. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 11 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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Each person has an individual plan of care, which provides staff with essential information about how best to support residents to live independent and safe lifestyles. EVIDENCE: Each resident had two care files, which were stored securely in the office. One a main file and the other a working file. The manager explained the purpose of both files. The main file is used to store information, which does not have to be used on a daily basis such as financial information, correspondence from hospitals and other medical services. Out of date assessments and care plans are also archived in the main file. The working file is used to store up to date information, which is used by staff on a daily basis. Relevant and up to date assessments, protocols, Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 12 support guidelines, medical information and support plans are the kind of documents, which were stored in each residents working file. New support plans described by the manager, have been implemented for each resident. Support plans have been put together using information following a detailed assessment of each persons needs. Assessments were carried out by the practice support team with the involvement of the resident, their family/representative, and the home manager and support staff. The practice support team is made up of professional health and social care workers including a speech therapist and are experts in the field of Autism and Aspergers syndrome. The team provide managers and staff with ongoing training around the use of the support plans and associated documentation. Resident’s individual care and support needs are identified monitored, reviewed and evaluated by use of support plans. A support plan is put in place for each particular area of need or goal. The plans aim to support residents to achieve independent lifestyles. Daily records, which are linked to support plans, are completed by staff during each shift. Support plans and associated records, which have been completed for two residents, were looked at in detail as part of the case tracking process. The plans covered areas of need such as communication, behaviour, personal, healthcare and social support. Daily recordings made for two residents were detailed and clearly linked to their support plans. They showed that each person is involved in the day-to-day routines of the home such as cleaning, cooking and laundry. Residents who have limited verbal communication skills are assisted to communicate by use of other means. Files containing a selection of pictures, symbols and photographs of objects, people, transport, activities, food and drink were displayed around the home. Staff explained how they are used to assist residents to make choices about such things as what to eat, were to go and activities at home. One resident also communicates using sign language and by use of his computer. This was demonstrated during the visit. Staff were seen communicating effectively with all residents. Kitchen cupboards and drawers displayed pictures of utensils and food items, which were stored in them to help promote residents independence. For safety reasons there are certain restrictions placed on residents for example access in the community and management of finances. There are also instances when some decisions and choices have to be made for residents Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 13 by others. Restrictions placed upon people and choices, which need to be made by others and the reasons why, were recorded in each person’s plan of care. Risk assessments were part of each persons care plan. They have been carried out for tasks and activities which residents are involved in that are likely to pose a risk to them. Risk assessments that were seen identified potential risks and hazards and detailed the action that staff need to take so that residents are able to take risks safely as part of an independent lifestyle. Risk assessments that were viewed showed that they have recently been reviewed and updated. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 14 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 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are encouraged and supported to live healthy and active lifestyles. EVIDENCE: Support plans and daily records put a lot of emphasis on personal development. They identify goals, which have been set around the person’s individual needs. Viewing of support plans showed that goals, which have been set, are closely monitored and appropriately actioned and that residents are given opportunities to learn and develop practical life skills such as social, communication and independent living skills. On the day of the inspection visit one resident was ironing his clothes. said, “I always iron my own clothes which I enjoy”. He Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 15 A member of staff was seen supporting another resident to carry out general cleaning tasks around the home. The member of staff said “I encourage all the residents to help around the house”. Each of the residents had a structured programme of activities. Case tracking showed that the programmes have been developed around each person’s daily routines, wishes and preferences as outlined in their plans of care. One resident who is more independent than the others travels around the community independently. He said the he enjoys the activities he is involved in and was fully involved in developing his weekly activity programme. He described the things that he does both at home and in the local community which included, trips to Liverpool, evening social groups, cooking, ironing and meals out. He said he had recently celebrated his birthday at a Chinese restaurant with a group of friends. Displayed around the home were a number of photographs of residents taking part in various outdoor activities such as canoeing, walking and social gatherings with friends. There were also photographs of all three residents and staff enjoying a recent activity holiday together. Seen at the home were a wide selection of board games, puzzles, videos and DVDs which one member of staff said are used by all three residents for entertainment at home. A resident confirmed this. Personal relationships are encouraged this was evidenced through discussion with residents and staff. One resident reacted positively when asked about a photograph of him and a group of friends enjoying a meal out. Another resident said “ I see my family when I want”. Staff explained that contact with family and friends are encouraged for all residents. Details of relationships and how they need to be supported was available in each person’s plan of care. Daily records showed that residents have plenty of contact with the community and the people who are important to them. Viewing of a three-week menu and discussion with people showed that residents are provided with and encouraged to eat a varied and healthy balanced diet. On the day of the inspection staff were seen supporting residents to choose and prepare their lunchtime meal. A resident that has limited verbal communication made his choices by use of pictures, symbols and photographs. A selection of files was seen in the kitchen. One of the files contained a wide selection of pictures, photographs and symbols, which the manager confirmed, are used on a daily basis to assist residents to make choices and decisions about food and drink. Information about resident’s likes and dislikes with regards to food was detailed in their plans of care. Residents are encouraged to shop for food and to help prepare meals. A resident said, “I always help with the shopping and I cook my meals and peel vegetables”. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 16 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 & 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Resident’s personal and healthcare is well monitored and supported ensuring that they are physically and emotionally well. EVIDENCE: Plans of care provided detailed information about the type and level of personal and healthcare support that each person requires. The persons preferred routines with regards to personal care were also available in very good detail. Information was available in a way, which ensures residents privacy, dignity and independence. During discussion staff showed that they provide sensitive and flexible personal support which ensures residents privacy and dignity. The following comments supported this: “When assisting residents with personal care it is important to make sure doors and blinds are shut”. “It is important to talk to residents when assisting them”. “All personal care should be given in private” Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 17 “I encourage residents to do as much as they can for themselves” Care plans clearly set out the person’s healthcare, needs and procedures that are in place to address them. Records showed that residents are offered minimum annual checks and that there health is regularly reviewed and monitored and dealt with appropriately. As well as visits to primary healthcare services such as dentist, opticians and doctors residents are also supported to attend specialist services. Records detailing the visits were available in good detail as was information about specialist health care needs and requirements. Support plans provided good information about how residents communicate when they are unwell or in pain. These are particularly important for a number of residents that have limited verbal communication skills. During this inspection visit all medication and medication administration records were examined. They were appropriately stored and in good order. The manager said that medication is only administered by staff that have completed medication awareness training. discussion with staff and records that were seen evidenced this. A weekly stock check of all medication is carried out by the manager records seen evidenced this. A policy for the safe handling and administration of medication was availble at the home. The manager showed a good awareness of the homes medication polices and procedures. One resident has some involvement in taking his own medications. The level of his involvement and the support he needs was clearly identified within his care plan. Discussion took place with the manager about how the resident could be supported to progress further with this task. The manager said that he intends to discuss this with the resident. The home records homely remedies appropriately. Since the last inspection the manager has followed through his intention to get permission from the residents G.Ps to administer homely medication. Written evidence of this was seen. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 18 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 & 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Procedures are in place, which aim to protect residents from abuse harm or neglect. EVIDENCE: There has been no complaints received by the Commission about the home since the last inspection. Discussion with the manager and staff showed that there have been no complaints made at the home in the last 12 months. There was a complaints procedure on display at the home. It was available in written and picture format. The manager said that residents friends and family also have the information that they need to make a complaint if they wish to. Staff spoken with said that would complain if needed to. The following comments supported this: “I would not hestitate to make a complaint if I need to” “I know how to complain and I would if I needed to”. Discussion with staff and examination of records showed that staff have received protection of vulnerable adults training. During discussion staff ahowed a good understanding about what they need to do if they witnessed or suspected abuse of a resident. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 19 A copy of the local authorities protection of vulnerable adults procedure was avaialbe at the home. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 20 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is a safe place for residents to live however some minor improvements would enhance their comfort. EVIDENCE: The home is located in a residential area of Southport, Merseyside. It is in keeping with other properties in the area and indistinguishable as a care home. Public transport links, healthcare services and a number of shops are close by. The home is in easy reach of the main town centre of Southport. A tour of the environment was carried out. The ground floor comprises of a lounge, and a large combined kitchen/diner. The lounge appeared homely and comfortable and was decorated and furnished to a good standard. The kitchen/dining area, which is at the back of the house looks on to and has access into the back garden. The dining table and some of the kitchen cupboard doors showed signs of wear and tear. Kitchen cupboard doors looked Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 21 tatty and some were would not close shut because they were off line. There was one door, which did not match the others. The dining table and chairs were also tatty in appearance. It is recommended that these items be repaired or replaced to enhance the comfort and dignity of the residents. Each of the residents provided a tour of their bedrooms. Bedrooms were personalised, they each included a good selection of furniture and were generally well decorated. However one resident’s room was showing signs of damp below the window. This was detailed to the manager who said that he would make the necessary arrangements of its repair. The home has a bathroom, a shower room and a separate toilet. A requirement was given as part of the last inspection for exposed pipe work in the shower room to be covered and for its redecoration. The pipe work has been covered but the room has not been decorated. This should be done to promote residents comfort, as there were some obvious signs of general deterioration including damp patches over the window. All parts of the home were clean and tidy staff were seen supporting residents to clean parts of the house. A member of staff said that residents are encouraged each day to take part in general household tasks. The home had available a number of policies and procedures which aim to ensure a hygienic and safe environment they included infection control and disposal of waste. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 22 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment and training procedures carried out at the home ensure that staff are fit and able to do their work. EVIDENCE: Two members of staff were interviewed during the inspection. General discussion also took place with other staff that were on duty at the time of the inspection visit. They showed commitment and a good understanding of their roles and responsibilities. Each member of staff was knowledgeable about the needs of the residents. Staff interviewed confirmed that they were given a copy of their job descriptions at the start of their employment. A Residents spoken with said thought that the staff do their jobs well. made the following comments, which supported this: “All the staff are s good at their jobs” “The staff know what they are doing” He Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 23 Available at the home was evidence to show that staff complete training to update their knowledge and skills and that the training is linked to the aims and objectives of the home and the needs of the residents. Staff spoken with said that they have completed a lot of training and gave the following examples, understanding autism, protection of vulnerable adults, health and safety equality and diversity and food hygiene. Training and development records which were looked at for a number of staff were very detailed and showed that staff receive a good level of training which is well recorded, monitored and supported by the manager. Discussion with people and records held at the home evidenced that at least half of the staff team have achieved or are currently undertaking a National Vocational Qualification in care level 2 or above. Staff made the following comments about training: “The training is excellent” “We receive ongoing training in lots of subjects” “The training is very good” Records examined and discussion with a new member of staff evidenced that strict processes were followed before they were allowed to start work at the home. The member of staff confirmed the following “I completed an application form” “I was interviewed ” “I wasn’t allowed to start work without references and a CRB check” “I took part in an induction training programme as soon as I started work here” Induction records for a number of staff were viewed. The homes induction programme is detailed and covers foundation training in areas such as understanding autism, health and safety communication and Protection of vulnerable adults. The structure of the organisation and the workers role within in it are also part of the induction. Records showed that all staff has CRB check and that they were carried out prior to them working at the home. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 24 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 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed to the benefit of both residents and staff. EVIDENCE: The registered manager Mr Steven Halewood has a number of year’s experience of working with people that have autism. He has achieved an NVQ level 3 and 4 in care. The manager has addressed most of the requirements and recommendations given as part of the last inspection report. Examination of a selection of records showed that he has improved and maintains records required by regulation. He showed a real enthusiasm and a commitment to ensuring high standards of care. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 25 The following comments about the manager were made during the inspection: “The manager is very good” “He really cares about the residents” “I can talk to the manager about anything” Discussion with the manager evidenced that he undertakes regular training and development to update his knowledge, skills and competence while managing the home. As part of the homes quality monitoring system residents, relatives and advocates are invited to complete surveys, which gives them the opportunity to put forward their views and make comments about aspects of the service for example, the manager and staff, the quality and choice of food, and the environment. The manager explained that the results of the surveys are used to monitor the quality of the service. Also As part of the homes quality assurance process and in accordance with Regulation 26 of the Care Homes Regulations a representative for the home visits the premises monthly. They interview residents and staff, check records and inspect the environment. It is important that this is done to check the standard of care in the home. Following the visit a report detailing the visit is written. Records show that the visits and reports are being carried out each month as required. The health safety and welfare of residents are well protected this was supported by a comprehensive set of policies and procedures, which were available at the home. Examination of a selection of health and safety records showed that the required health and safety checks have been carried out on the environment at the required intervals, for example fire system checks, gas and electricity checks and environmental risk assessments. As part of the last inspection a discussion took place with the manager regarding concerns he had surrounding fire safety. The manager revealed that by attempting and supporting one service user to be more independent this had resulted in a bedroom door being wedged open over night. The service has one waking staff member. The manager also expressed his intention to discuss escape routes with the fire officer as both the front and back doors require keys to unlock them to leave the building. Since then a fire officer has visited the home and provided the manager with advice in relation to these issues. Written evidence of this was seen. Wedges are no longer used during the night and the doors have been fitted with more appropriate locking devices ensuring the health and safety of residents and staff. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 26 A requirement was given as part of the last inspection for the manager to ensure that fire drills are recorded. Records that were viewed during this inspection visit showed that regular fire drills take place and are now being recorded to show when the event took place and the people involved. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 27 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 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 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 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 3 3 X 3 X 3 X X 3 X Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 28 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. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. Refer to Standard YA24 YA24 YA5 Good Practice Recommendations The shower room should be redecorated following repairs, which have recently been carried out. Kitchen cupboards and the dining table which are showing signs of wear and tear should be repaired/ replaced to enhance the comfort and dignity of the residents Were possible contracts of residency should be provided in format, which can be easily understood by residents. Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS 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 Sefton Street, 132 DS0000005227.V334647.R01.S.doc Version 5.2 Page 30 - 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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