Inspection on 15/03/06 for Southport Road, 119

This inspection was carried out on 15th March 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 8 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Southport Road, 119 25/06/09

Southport Road, 119 02/04/07

Southport Road, 119 28/06/06

Southport Road, 119 14/07/05

Southport Road, 119 07/02/05

Southport Road, 119 27/09/04

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 Southport Road, 119 119 Southport Road Lydiate Liverpool Merseyside L31 2JW Lead Inspector Ms Lorraine Farrar Unannounced Inspection 15 March 2006 05:35 th Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Southport Road, 119 Address 119 Southport Road Lydiate Liverpool Merseyside L31 2JW 0151 526 2849 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) Expect Limited Ms Susan Byott Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. Service users to include up to 3 LD The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Variation to admit one named service user over the age of 65 with LD and MD. This condition will cease when that service user leaves the home. Date of last inspection 14th July 2005 Brief Description of the Service: 119 Southport Road is a small home registered to provide accommodation and support for three adults who have learning disabilities. The home is run by Expect LTD a local organisation who provide support to adults with learning disabilities or mental health support needs. This includes support in all areas of daily living including personal care, leisure and health and safety. Staff are available 24 hours a day, there are usually two staff during the day and two staff sleeping in during night time hours. The building is owned by Liverpool Housing Trust who take care of maintaining the premises. The home is a detached bungalow in a residential area of Lydiate and blends in well with other houses in the local area. Accommodation includes, 3 single bedrooms, a through lounge / dining room, 2 bathrooms, a kitchen, enclosed rear garden and staff room / sleep in room. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection of the home. Information for the inspection was gathered in a number of different ways. This included, talking with staff and meeting with service users, reading samples of care files, records and documents in the home and a partial tour of the building. What the service does well: What has improved since the last inspection? Since the previous inspection of the home in July 2005 improvements have been made to the overall cleanliness and appearance of the home. A new settee has been purchased and work carried out to the damp in the hallway. Access to staff files is now available to the manager and at inspection. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 6 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. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Service users needs and choices are assessed prior to them moving to the home. This helps the home to make sure they can offer a suitable service for the person. EVIDENCE: A care file was looked at for a service user who recently moved into the home. This contained a detailed risk assessment stating the actions to take to lessen any risks identified. A detailed assessment had also been carried out by the home and information about the person obtained from other places they had lived and other professionals who are involved in supporting the service user. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6&7 Care plans are in place for each service user and contain some clear detailed information. However other information is out of date and does not reflect the person’s current needs and choices. Service users are supported to make decisions about their daily lives. EVIDENCE: Two care plans were read, one of these was for a service user who had recently moved into the home and the other for a service user who has lived there for some time. Some of the care information for one service user was based upon information from the person’s previous home and a member of staff explained that not all of this was current. For example the care file recorded that the person likes a particular design on their clothes and can become upset without this. Staff explained that this no longer appeared to be an issue and in fact the person did not have any clothes with that logo on. The home needs to make sure that care plans for new service users are reviewed regularly to make sure any new or changing needs and choices are identified recorded and acted upon. Information about the person’s triggers and protocols for supporting them to manage their behaviour were in place and provide clear, detailed information for supporting the person. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 10 A second care plan contained in-depth information about the person, their support needs, choices and communication and provided a good basis for staff to provide individual support. During the inspection service users were seen to make requests of staff, in one instance a service user requested to go out. Staff were seen to take the time to explain they would support the person with this and the reasons why it could not happen immediately. Care plans contain information about how the person communicates and how this can be understood. Staff spoken with were able to explain how each service user communicates their choices and decisions. Where service users rights are restricted there are clear guidelines and protocols in place. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 11 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 15 & 16 Appropriate polices and procedures are in place for supporting service users to maintain and develop relationships. Daily routines in the home are as flexible as possible based on the person’s choices. EVIDENCE: The homes service user guide states that service users visitors are welcomed to visit the house at reasonable times. The organisation have a policy and procedure in place to provide guidelines for staff to support service users with personal and intimate relationships. Service users have some, limited opportunities to meet people without disabilities via their participation in the local community. Staff were seen to obtain the persons permission before entering their bedrooms and to spend time interacting appropriately with service users. Staff spoken with were able to give good examples of the different ways people are supported based on their preferred routines. Service users were seen to make use of communal rooms as they choose, the home has an enclosed back garden and this is accessed by service users in warmer months. Access to the front is restricted as the front garden leads directly to a busy main road. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 12 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 Service users personal care needs are met in line with their needs and choices. However service users are not always supported to attend regular healthcare checks at recommended intervals. EVIDENCE: Care plans contain detailed information about the support service users needs with their personal care needs. This includes information about their preferred routines, times they like to get up / go to bed and whether they like to use the bath/ shower. Staff spoken with were able to explain each persons routine and how they make their choices known. A care file looked at contained a health action plan to make sure the person attends regular healthcare checks such as the dentist, within recommended timescales. This plan had not been updated and it appeared that some health appointments were overdue. The home must make sure these records are updated regularly and appointments made at appropriate times, this is a previous inspection requirement that the home had not met. The standard around medication was not full looked at during this inspection, however a check was made on a previous inspection requirement regarding medication training for staff and this had not been complied with. A member of staff advised that training was booked for April however no record of this could be located. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 13 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 home has appropriate complaints and adult protection policies and procedures in place. EVIDENCE: The organisation have an appropriate complaints procedure in place copies of which are made available to service users via the service user guide. No complaints have been received regarding the service since the time of the last inspection. The home has a copy of the local authorities adult protection procedures and most staff have received training in this area. A staff handbook has been recently updated and contains information for staff about the organisations whistle blowing policy, a member of staff explained that all staff had been given a copy of this. Records and amounts of monies for two service users were checked and were in order. There are clear protocols in place for supporting service users to manage their behaviour. A service users care file stated that all care staff had received training in non-violent crisis intervention and that a refresher course would be arranged to allow the team to undertake this together. A member of staff spoken with confirmed they had received this training but was unaware of any date arranged for team training. It is a recommendation of this report that the organisation provides this training for the team so that everyone is clear as to their role in the event an incident occurs. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 14 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): X EVIDENCE: These standards were not fully measured during this inspection. However a partial tour of the building relating to requirements from the last inspection was undertaken. It was noted that the home was in a cleaner condition than the last inspection; work had been carried out on damp in the hallway and in bathrooms and a new settee purchased for the lounge. Bathrooms were also noted to be cleaner with some work having been carried out. The main bathroom did not have any window covering, although there is frosted glass fitted this could affect service users privacy. Therefore the home must provide a form of window cover for this room. One service user has had a ‘fence’ erected yards from their bedroom window. Staff advised this was to protect the person’s privacy and was an interim measure however it provides no view from their window. The home must provide an alternative this arrangement, which both protects the person’s privacy and provides a view from their window. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 15 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): 32,34 & 35 Staff have a good knowledge of service users and are competent in their role. There is a clear recruitment policy in place to protected service users however evidence that this is followed is not always available. Staff receive some training to support service users, however there is no formal planning in place to ensure this meets service users needs or that it is up to date. EVIDENCE: It was a requirement of the last inspection that the organisation ensured the manager had access to staff files. At this inspection arrangements were in place for the inspector to view files. However of the three staff on duty files were only available for two. A member of staff explained that the third member of staff had recently transferred to the home and the file may not have been sent over. Therefore training records for all staff could not be viewed and no training matrix for staff was available as recommended at previous inspections. This recommendation is repeated at this inspection, a training matrix will enable the home to plan training for all staff based on service users needs and care standards and will help them to ensure staff are up to date with training courses. The staff files looked at evidenced that training does take place, with recent training including, 1st aid, crisis intervention, the role of the support worker and abuse. Both files evidenced that the staff had obtained a care qualification (NVQ) and a member of staff stated that most staff working in the home hold this qualification. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 16 Staff spoken with had a good understanding of service users, their needs and choices and were seen to communicate effectively with service users throughout the inspection. The home has a recruitment policy in place, which states they will obtain required checks and references. However this could not be fully evidenced from the information in the home. A newer member of staff explained the recruitment process they had undertaken. This included, completing an application, interview and checks including 2 references and a Criminal Records Bureau Check (CRB). Files for two other members of staff did contain 2 written references. As required at the previous inspection the home must make sure that they have all the information in the home regarding staff that is required by schedule 4 of the Care Homes Regulations 2001 and evidence that they have obtained the information regarding staff required by schedule 2 of those regulations. This will provide a clear audit trail for ensuring the recruitment process has followed the organisations procedures and ensured the protection of service users. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37 & 39 There is no registered manager operating the home at present. The organisation do have systems in place for auditing the service however they do not always meet inspection requirements within given timescales. EVIDENCE: It was a requirement of the last inspection that the organisation must apply to the CSCI to register a manager for the home. An application was received however that member of staff has now left the home. The organisation have advised the CSCI that they have arranged for an experienced carer, familiar with the home to manage in the interim and intend to advertise the post. The requirement to apply to register a manager has therefore been repeated with an extended date for compliance. Each year the responsible person from the organisation carries out a quality assurance check. A copy of the last audit carried out in August 2005 was seen, this contained clear information and recording of the findings. In addition the organisation carry out monthly visits to the home and send a report to the Commission for Social Care Inspection (CSCI) of their findings. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 18 The organisation regularly review their polices and procedures taking into account new legislation and practice issues. Not all requirements from the last inspection of the home have been complied with. These have been identified throughout the report and repeat requirements given. These requirements are based on regulations for care services and should be met as they help to ensure service users are receiving a safe, high quality service. The standard around health and safety was not fully looked at during this inspection. However a check was made on a previous requirement stating that the home must make sure all staff regularly participate in fire drills. At this inspection the fire book could not be located and therefore the homes compliance with the requirement could not be checked. Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 2 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 3 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 2 X X X X 2 X X X X X Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 20 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 YA20 Regulation 18(1)(c) Requirement The home must ensure that all staff who handle service users medication have recieved accredited training This is a previous inspection requirment. The home must ensure staff files contain all the information required by the Care Homes Regulations 2001. This is a previous inspection requirement. The organisation must apply to the CSCI to register a manager for the home. The home must offer residents support to make regular healthcare appointments. This is a previous inspection requirement. The home must make sure that all staff take part in regular fire drills. This is a previous inspection requirement. Timescale for action 13/06/06 2 YA33 17(1) 19(1) 16/05/06 3 YA37 8(2) 31/07/06 4 YA19 12(1)(a) 16/05/06 5 YA42 23(4)(e) 30/04/06 Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 21 6 YA26 12 (4)(a) 23(2)(a) The home must make alternative arrangements outside the bedroom identified at inspection. These arrangements must protect the service users privacy and provide a view from their window. The home must fit a window covering to the bathroom window. The home must ensure that the service user identified at the inspection has their care plan updated regularly during their trial period. 11/08/06 7 YA27 23(2)(a) 16/05/06 8 YA7 15(2)(b) 30/04/06 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 Refer to Standard YA35 YA35 Good Practice Recommendations The home should complete a training matrix for all staff. This is a previous inspection reccomendation. The organisation should offer staff the opportunity to undertake training via the Learning Disability Framework. This is a previous inspection reccommendation. The organisation should arrange for the staff team to receive non-violent crisis intervention training together. 3 YA23 Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Southport Road, 119 DS0000005278.V277361.R01.S.doc Version 5.1 Page 23 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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