CARE HOME ADULTS 18-65
Sefton Street, 132 132 Sefton Street Southport Merseyside PR8 5DB Lead Inspector
Mr Paul Kenyon Unannounced Inspection 09:30 24 and 27 October 2005
th th Sefton Street, 132 DS0000005227.V257445.R01.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 Sefton Street, 132 DS0000005227.V257445.R01.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. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 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) Autism Initiatives Mr Roger Cameron King Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. Service users to include up to 3 LD Date of last inspection 31st January 2005 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. Stephen Halewood currently manages the service. He has applied to become the Registered Manager of the home and is undergoing the registration process with the Commission for Social Care Inspection. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was the first inspection to be undertaken at 132 Sefton Street this inspection year (April 2005 to March 2006) and was unannounced. The inspection was divided into two parts. The first part focussed on requirements form the last inspection as well as a general discussion with the current acting manager. The second part of the inspection was unannounced and involved discussions with the staff team, residents, a tour of the premises and an examination of systems and procedures. In total the inspection lasted four hours. The nature of the disability of residents using the service is such that it is not always possible to gain direct views about their experiences. Efforts were made by the Inspector to either observe care practice and to gain the views of one individual whose comments are summarised in this report. What the service does well:
The service is good at ensuring that assessment information is gained for individuals as they are admitted. One resident had been admitted since the last inspection. This person had resided with the organisation yet in another specialised provision. The person was well known to the organisation but not necessarily 132 Sefton Street. Information was obtained allowing a judgment on whether the needs of the person could be best met in the service. The home is run by an organisation that specialises in supporting those adults who have autism. As a result the staff team within the home are trained in many topics that are related to the needs of residents. As a result the needs of residents are taken into account by a well-trained team. The service is good at producing clear care plans. These are reviewed on a regular basis and as much as possible the agreement of the resident is obtained. This was evidenced through discussions with one resident who clearly stated that contact with the staff team on a day-to-day basis enabled issues to be discussed and agreement reached. The service provides safe systems of medication storage, record keeping of medication and training for staff. The service is good at striving to protect residents. Systems are in place to ensure that staff are aware of the policies for reporting allegations of abuse, being trained in abuse awareness, knowing that they are not allowed to be involved in resident finances, being aware of the role of the Commission for Social Care Inspection as an external vehicle for the dealing with concerns about care practice.
Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 Page 6 Residents are further protected through a robust recruitment procedure with personnel files evidencing the various checks made before staff commence work on a permanent basis. Staff are good at communicating with residents. It is clear that the disability experienced by residents is taken into account by the staff team and an informal approach is used. Staff adopt a consistent approach in dealing with any recurring comments from residents linked to their disability. The nature of the disability of residents is such that it is not always possible to elicit a direct response about their experiences from them. One resident confirmed that he was ‘alright’, another resident was able to state in an indirect way through discussions that staff ‘listened to him’, ‘encouraged me and that he felt ‘safe’ living at 132 Sefton Street. What has improved since the last inspection? What they could do better:
A requirement at the last inspection noted that representatives of the organisation did not provide evidence of their monthly unannounced visits to the service to check on the quality of the support provided. This has been partially met with the Commission for Social Care Inspection having received copies of these reports. The home has not received any recent copies with the last available being from June 2004. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 Page 7 The service must make create contracts of residency that in a more appropriate format for residents so that the details of the service offered is more accessible to them. The service also needs to ensure that where residents cannot sign these contracts that they are signed on their behalf by a representative who is independent form the service. Risk assessments relating to individuals must be reinforced. This inspection noted through discussions with staff that the risk posed to one resident from being in the kitchen is well known to staff but has not been formalised into a written risk assessment. The service also needs to ensure that all risk assessments are signed once completed and that all staff sign to confirm awareness of the assessments. The communication needs of one resident are such that using signs is the main method for passing information onto this person. The complaints procedure must be presented in a format that is understood by this person. The home needs to have a clear and written refurbishment plan that covers the next twelve months so that issues concerning the environment covered in this report can be addressed. This is raised as a recommendation in this report. The service needs to ensure that general hazards that may be present for staff in general work practices are assessed annually. The risk assessments are available but evidence suggested that these had last been done in May 2004. 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. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 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.V257445.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3 and 5 Residents have information about the role of the Commission for Social Care Inspection. The needs and aspirations of residents are known to the service and needs of residents are met through staff training. EVIDENCE: A requirement at the last inspection relating to the statement of purpose has now been addressed. This required the contact details of the Commission for Social Care Inspection to be included within the document. Assessment information relating to the most recently admitted resident was examined. This individual had been within another specialised service run by the same organisation, Autism Initiatives, and as a result his needs were known by the organisation. In order to become familiar with his needs, the home has gathered all this information and as a result risk assessments and care plans have been devised from this information. The home specialises in supporting those adults who primarily have autism. Training records suggested that all staff have attended or will have the opportunity to attend awareness training related to this specialism. Additional and related training has been provided in relation to Makaton (sign language) used by one resident as his main means of communication, Aspergers syndrome (an autism related condition) and epilepsy. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 Page 10 Contracts relating to the terms of residency were examined for all residents. These had not been put into a format that is appropriate to the needs of residents. In addition to this, the Acting Manager acting as the resident’s representative had signed one contract. It is required that formats are more appropriate and that an independent person acts as the resident’s representative in this matter. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 9 Residents benefit from clear and regularly reviewed care plans. Risk assessments need to better formalised and communicated to staff. EVIDENCE: Care plans for all three residents were examined. Reviews have been conducted with the exception of one resident who has only come into the service of late and whose plan of care is not yet subject to a review. Care plans contain short term and long-term goals as well as aims that are linked to the health needs of individuals or social care needs. Pen pictures are also included within care plans as well as an indication of their preferred routines. Care plans have been signed by residents wherever possible confirming their agreement with their plans. Risk assessments relating to all residents were examined. Risk Assessments relating to one resident had been devised with appropriate action taken within the environment with the installation of a fire detection system in order to reflect this risk assessment. Risk Assessments covered a variety of activities within the home as well as activities taking place outside in the community. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 Page 12 One area of risk was discussed with staff relating to one resident concerning access to the kitchen within the house. No risk assessment to reflect the action needed by staff was available. This is raised as a requirement in this report. In addition to this, risk assessments had not been signed when reviewed and not all staff had signed risk assessments to confirm they were aware of its contents. These are also raised as requirements in this report. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 Page 13 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): No standards in this section were measured during this inspection. EVIDENCE: Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20 Residents benefit from a safe system of medication. EVIDENCE: Medication is stored in a secure cabinet. Two residents have been prescribed medication at present with no one self-medicating at present. All medication records have been signed appropriately after medication and the same records include details of the amount of medication received on each occasion. Training records were examined. Certificates evidenced that staff had attended medication awareness training. Sefton Street, 132 DS0000005227.V257445.R01.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 and 23 Complaints procedures do not take the communication needs of all residents into account. Residents are protected from abuse. EVIDENCE: A written complaints procedure is available and includes reference to the Commission for Social Care Inspection as an investigator of complaints as well as a timescale for their investigation. No complaints have been received by either the service or the Commission for Social Care Inspection. One resident who has been admitted into the service since the last inspection has communication needs that rely on the use of signs and symbols. It is required that a format is developed so that this individual has the information needed if concerns or complaints wished to be raised by him. The service has a procedure relating to abuse and evidence was available suggesting that all staff had received abuse awareness training. There is a clear protocol in place for the reporting of any allegations within the company and this is on prominent display for staff reference. Other policies permit staff to be involved in finances connected to residents and a clear whistle-blowing procedure is available for staff in the event of any concerns they have about care practice. Reference is made in this to the Commission for Social Care Inspection. The recruitment procedures outlined in Standard 34 of this report further enable residents to be protected. Sefton Street, 132 DS0000005227.V257445.R01.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 Generally residents benefit from a home-like environment. A recommendation is raised in respect of planned refurbishment both internally and externally. EVIDENCE: The service is operated from a semi-detached property in a residential area of Southport, which is close to local amenities and facilities. The service blends in with the local area and cannot be identified as a residential care home. The exterior of the property needs a degree of attention. This includes repainting of some window frames. The interior of the home is generally well presented with no offensive odours and the premises appeared clean and hygienic throughout. Some improvements have been made internally with the fitting of new kitchen worktops and a fire detection system has been installed in response to one resident’s risk assessment. Some improvements are needed internally, for example, a carpet in the hallway has become stained and detracts from other areas of the building. Other general wear and tear to the decoration of the building has also occurred. As a result of this, it is recommended that a refurbishment plan be drawn to up to identify which areas of the home are to be decorated over the next twelve months. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 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): 34 Recruitment of staff is robust and residents are protected. EVIDENCE: Personnel files were available for inspection. A total of four files were examined relating to those staff members who had commenced employment since the last inspection in January 2005. All contained a minimum of two references as well as information that confirmed the identity of the staff member concerned. Criminal record checks had been carried out on all individuals with reference made to the Protection of Vulnerable Adults register. All files are securely stored away. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 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): 39 and 42 The quality assurance process does not provide outcomes to the Acting Manager. Health and Safety systems do not fully protect the health and safety of staff. EVIDENCE: The Commission For Social Care has received copies of the monthly visits that are made to the home under care home regulations. These copies are not provided to the Acting Manager. As a result the Acting Manager cannot refer to any progress the service is making. The last visit on file related to a visit undertaken in 2004. This is raised as a requirement in this report. Training records suggested that staff had received training in a number of mandatory topics such as fire awareness, first aid, health and safety and manual handling. Fire alarm systems are checked regularly as well as emergency lighting systems. The most recent fire drill took place in October 2005. All accidents and incidents are recorded. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 Page 19 Hand washbasins are fitted with thermostatic valves although water temperatures are checked to ensure that temperatures are maintained. Information is available on substances that are hazardous to health. General risk assessments are available but were last reviewed in 2004. It is required that these are reviewed within a twelve-month period. Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score X X 3 X 2 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 X X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 X 17 Standard No 31 32 33 34 35 36 Score X X X 3 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Sefton Street, 132 Score X X 3 X Standard No 37 38 39 40 41 42 43 Score X X 2 X X 2 X DS0000005227.V257445.R01.S.doc Version 5.0 Page 21 YES Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard YA5 Regulation 5 Requirement Contracts of residency must be in an appropriate format to meet the needs of residents. Contracts of residency must be signed by independent representatives where residents are unable to sign All staff must sign individual risk assessments relating to residents A risk assessment relating to one resident using the kitchen area must be put into writing Risk Assessments must be signed when reviewed A complaints procedure meeting the communication needs of one resident must be developed Copies of monthly visits to the home by a representative of the organisation must be made available to the Acting Manager General risk assessments must be reviewed annually. Timescale for action 30/11/05 2 YA5 5 31/12/05 3 4 5 6 YA9 YA9 YA9 YA22 13 13 13 22 30/11/05 30/11/05 30/11/05 31/01/06 7 8 YA39 YA42 26 13 30/11/05 30/11/05 Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 Page 22 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA24 Good Practice Recommendations A refurbishment plan outlining proposed decorative work over the next twelve months to the interior and exterior of the home should be devised Sefton Street, 132 DS0000005227.V257445.R01.S.doc Version 5.0 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
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