Inspection on 02/04/07 for Southport Road, 119

This inspection was carried out on 2nd April 2007.

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 there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 4 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 28/06/06

Southport Road, 119 15/03/06

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 Mrs Janet Marshall Unannounced Inspection 2nd April 2007 10:00 Southport Road, 119 DS0000005278.V332855.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 Southport Road, 119 DS0000005278.V332855.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. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 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.V332855.R01.S.doc Version 5.2 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. 28th June 2006 Date of last inspection 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. There are currently two people living there. The home is run by Expect Limited a local organisation that provide support to adults with learning disabilities or mental health support needs. This includes support with in all areas of daily living including personal care, leisure and health and safety. Staff are available 24 hours a day, there is a minimum of two staff on duty during the day and night. The property is owned by Liverpool Housing Trust who has to 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. Lynn Thompson was appointed as manager of the home following the last key inspection, which took place in October 2006. It costs £318.00 per week to live at the home. Southport Road, 119 DS0000005278.V332855.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 for Adults (18-65) as Key Standards, which have to be inspected during a Key Inspection. Evidence for this report was gathered from previous inspection reports, the pre-inspection questionnaire, records held by the Commission and a visit (site visit) to the home. The visit, which was unannounced, took place over one day for a total of 6 hours. During the visit a tour of the home was carried out, a selection of care records and other required records were inspected. One to one and group discussions took place with the staff on duty and the manager. The nature of the disability of the residents is such that it was not always possible to obtain direct views about their experiences, however, non-verbal communication and general observations took place throughout the visit and have been used towards measuring standards for the purpose of this report. Both residents were “case tracked”. Case tracking means that the Inspector concentrates on the care given and experiences of one or more residents to get an idea of what is like to live at the home and how that person’s needs are being met. What the service does well: The service has procedures in place, which aim to ensure that prospective residents needs are fully assessed so that the home can be sure of meeting the person’s needs. The manager was knowledgeable about the process for assessing the needs of prospective residents and admitting new residents to the home. Each of the residents had a care plan, which clearly set out how staff need to support them to live an independent lifestyle. Residents are supported to make choices and decisions so that they have maximum control over their own lives. Residents take part in a range of activities both inside and outside of the house enabling them to be part of the local and wider community. Residents are appropriately supported with personal and healthcare needs, which ensures that they remain healthy. Resident’s benefit from a staff team that have a good understanding of their roles and responsibilities and have the qualities and competencies required for the job. Staff receive a good level of training, which is linked to the aims, and objectives of the home and the needs of the residents. The manager showed a good understanding of her role and responsibilities and an enthusiasm for ensuring high standards of care. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? 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. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information was available about procedures that need to be carried out to ensure that a person chooses the right home for them. EVIDENCE: Both resident’s personal files were looked at. Available at the home was a service user guide and a statement of purpose. The documents provide details about the services and facilities provided by the home. The management structure and staff details are also contained within the documents. Both residents care files contained a need assessment, which was carried out by the service prior to admission. The assessments were comprehensive and detailed what support residents need and what tasks they can do for themselves. Information about past medical and psychological health was also available in good detail. The files also contained pre admission information from other sources such as social services, which also help the service build up a picture of a residents needs before they move in. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 9 Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 10 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. Residents are encouraged to live independently and are supported to take risks, which are managed safely. EVIDENCE: A care plan was available for both residents. They were both looked at during the visit. The plans covered all aspects of the person’s personal and social support and healthcare needs such as, communication, medication, behaviour management, risk management and financial support. Care plans set out how the person needs to be supported to live the kind of live that they choose safely and independently. Records showed that care plans are regularly reviewed and updated with the involvement of the resident/representative, manager and key workers. The manager provided evidence to show that she is in the process of carrying out an annual review of each persons care plan. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 11 Residents have limited understanding so were unable to comment about their care plans. During discussion staff explained in good detail the purpose of care plans and how they use them on a daily basis to support residents. Staff made the following comments about how they assist residents to make everyday choices and decisions. “Read the persons care plan to get to know the things that they like” “I ask them to choose what they would like to eat” “Give residents as many choices as possible” “It is important to be patient and not to rush a person” Daily records are kept for each resident. The records, which are written by staff during each shift provide information about how the residents have spent their day residents routines and progress the records are used as part of reviews As part of the last inspection a selection of daily notes for one resident was looked at. Recorded in the notes were a number of incidents when the resident had displayed challenging behaviour. However, there was little or no information about how the incidents were supported and managed nor did they include details of the outcome. There were clear support guidelines in place on how these situations should be managed in a positive way and to the benefit of the resident. Discussion with the manager evidenced that staff do follow the guidance with positive outcomes. The manager was advised that this information should be recorded to show that staff are supporting residents appropriately and with good effect. The residents daily notes which have been written since the last visit were looked at again as part of this inspection and included more detailed information to show that residents needs are being appropriately met. For safety reasons there are certain restrictions placed on residents for example, use of keys, access without support to certain parts of the home and the community, management of money and medication. There are also instances when some decisions and choices have to be made for residents 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. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 12 Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 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. 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 supported to live enjoyable and healthy lifestyles. EVIDENCE: Neither of the residents is currently involved in any educational or training programmes. Discussion with the staff and details provided in the preinspection questionnaire showed that residents are supported to take part in a range of tasks and activities both at home and in the local community. Activities include swimming, listening to music walks, shopping, drawing and meals out at local cafes and pubs. Both residents are totally dependent on staff for support in accessing the community. Care plans, which were looked at, contained a lot of information about the persons preferred lifestyles and any help that they need with tasks and activities. Daily records showed that residents are supported to live the kinds of live that they choose. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 14 Care plans had information about important personal and family relationships and how staff need to support them. Residents are encouraged to take part in routines at the home as part of an independent lifestyle. For example helping with small tasks such as tidying around the home and shopping for food. Residents do not have keys to their rooms because of certain limitations. Restrictions such as this are recorded in the persons care plan and agreed by the appropriate people. Residents are encouraged not enter each other’s bedrooms unless they are invited. Staff were seen knocking before entering residents bedrooms. The home has a large kitchen, which is of domestic style. It was bright and clean and equipped with domestic style appliances such as a microwave, fridge and freezer. There was a small dining table in the kitchen, which is used by one resident who prefers to sit and eat meals there whilst the other resident chooses to sit at the larger dining table, which is situated in the homes main dining room. Consideration should be given to refurbishing the kitchen because the kitchen units, worktops and the décor were showing signs of wear and tear. There was plenty of cutlery, pans, cups and dishes, which were in good condition. Food stores were examined. There was items of fresh, frozen and dries food at the home. A four-week menu is operated at the home. Copies of the menu that were sent with the pre-inspection questionnaire were seen. They were varied and healthy in content. Staff closely monitor and support a resident who requires a special diet. Details of the person’s dietary needs were recorded in their care plan. During discussion a member of staff showed a good understanding of the persons dietary needs and the variety of food that the person needs to eat to stay healthy. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 15 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 adequate. This judgement has been made using available evidence including a visit to this service. The home provides residents with appropriate personal and healthcare support to ensure their physical and emotional well-being, however the recording of medication does not always ensure the full protection of residents. EVIDENCE: Care plans for both residents had information about bout routines and the type and level of personal and healthcare support that they need. Residents are encouraged to carry out their own personal care were possible. Case tracking showed that residents are given support in accordance with their plan of care. Due to limitations residents were unable to comment on the quality of care given by staff, however during the visit staff were observed maintaining and encouraging residents privacy, dignity and independence. They were seen treating residents with respect, they spoke to them in a polite way and responded to them positively. Staff made the following comments: “I always shut doors when assisting residents with personal care” “I always knock before entering residents bedrooms and bathrooms that they are using” Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 16 “It is important to talk to residents and explain what you are helping them with” Each of the residents care plan had a healthcare section which provided staff with detailed information about their health and personal care needs and how best to support them. Records within this section showed that residents are offered minimum annual checks and their general and mental health is regularly reviewed and appropriately monitored and acted upon. Information given in the pre-inspection questionaire and records that were looked at showed during the visit showed that residents are registered with a local GP and use other healthcare services in the local community. A selection of medication and medication administration records were examined. Medication and records were safely stored. Details of medication and up to date information about it such as possible side effects was available as part of each persons personal medication records. Medication Administration Record (MAR) for one resident showed a number of gaps were it had not been signed at the appropriate time in the month of March 2007. this put the resident at risk as there was no guarentee that they had received prescribed medication. The manager was advised of this and the need to ensure that all medication records are signed at the appropriate time to show that residents have received treatment and/or medication on time. Details provided with the pre- inspection questionaire showed that the home has available policies and procedures for the safe handling and administration of medication. Medication is only administered by staff that have completed medication awareness training. Records that were seen evidenced this. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 17 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. The home has in place the necessary policies and procedures, which aim to ensure that residents are protected from harm, neglect or abuse. EVIDENCE: There has been no complaints received by the Commission about the home since the last inspection. Information provided in the pre-inspection questionnaire and discussion with the manager showed that there has been one complaint made to the home in the last 12 months. Discussion with the manager and records checked showed that the complaint was dealt with in the appropriate way. There was a complaints procedure on display at the home. The complaints procedures is also summarised in the homes statement of purpose and resident guide. Staff spoken with showed good knowledge and understanding of the homes complaints procedure. They made the following comments which supported this: “I know about the complaints procedure, I would complain if I needed to” “I would definitly complain if I needed to” Discussion with staff and details provided in the pre-inspection questionaire showed that staff have received protection of vulnerable adults training. During discussion staff showed a good understanding about what they need to do if they witnessed or suspected abuse of a resident. A copy of the local authorities protection of vulnerable adults procedure was avaialbe at the home. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 18 Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 19 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 poor. This judgement has been made using available evidence including a visit to this service. The environment is not a completely comfortable or safe place for residents to live, as there are parts of the home, which are in a poor state of repair. EVIDENCE: The last inspection took place in the evening when it was dark so it was not possible to inspect the outside of the home. The exterior of the house which has been painted since the last inspection looked clean and well maintained except for a small patch of woodwork at the rear of the house which showed signs of wood rot. This needs repairing to prevent it spreading further. The garden was a in a poor state. The lawn was over grown and the borders were covered in weeds. A section of the lawn was also over grown with weeds and bushes. The manager reported that that part of the garden is not used by anybody because it is damp and uneven. The manager was advised to make arrangements to have this part of the garden landscaped or made safe by other means and for the rest of the garden to be appropriately maintained so that it is a safe and pleasant environment for residents to use. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 20 The garden fence between the home and business premises next-door needs to be heightened to provide more privacy for the residents. During the inspection men that were working could clearly see over the fence directly into the garden, which compromises the privacy and dignity of the residents. There was a sectional garage in the rear garden close to the house. The garage was in a very poor state of repair. The manager reported that the garage is not in use and plans have been made to remove it. The garage must be removed as a matter of priority to minimise the risk to residents and staff, as there is a danger of it collapsing. There were a number of items of unwanted furniture and fittings disposed of in the back garden. These must be removed as they are a trip hazard and pose a risk to the safety of the residents. A full tour of the inside of the house took place. The condition of the decoration and some items of furniture particularly in communal areas appeared to have deteriorated quite significantly since the last inspection. For example wallpaper was damaged and discoloured in the lounge and dining rooms, general paintwork throughout the house was discoloured and chipped in places and curtain rails were hanging off walls. All the internal doors throughout the home were in poor condition. The décor in the shower room was poor. Bathroom fittings, which were broken, had not been removed and replaced. During the inspection Mr fieldsend responsible person for Expect visited the home with another member of the management team. During a further tour of the premises they were advised of the required improvements. Mr Fieldsend agreed to make arrangements for the improvements and repairs to take place as soon as possible. On the day of the inspection visit all parts of the home were clean and tidy. The pre-inspection questionnaire detailed a number of policies and procedures available at the home, which relate to the environment including infection control and disposal of waste. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 21 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. Residents benefit from a staff team that have good qualities and are competent and qualified to do their jobs. EVIDENCE: Recruitment, selection and equal oppertuities policies and procedures were available at the home. Recruitment information for a number of staff was not available at the last inspection. A requirement was given as part the last inspection report to ensure that all staff files are available for inspection. Without this information there was no guarantee that all staff were appropriately recruited putting residents at risk. There was evidence at this inspection to show that the requirement has been met. All staff files were available at the home a selection of them were checked and contained all the required information. There has been one new member of start that has started work at the home since the last inspection. the member of staff who was on duty said that they took part in an induction programme during the first part of their employment. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 22 There were two support staff and the manager on duty at the time of the visit. Discussion with staff and examination of staffing rotas showed that there is a minimum of two staff on duty at all times and there are many occassions when there are three staff on duty. Both residents benefit from one to one support. Records looked at during the last inspection showed that some staff needed to attend refresher courses in areas of mandatory training. Details of future training was provided in the the pre-inspection questionaire and included refresher courses in the following subjects, protection of vulnerable adults, medication awareness, health and saftey and manual handling. Other planned training includes learning disability award framework, NVQ level 4 in care, report writing and stress management. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 23 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 adequate. This judgement has been made using available evidence including a visit to this service. The home is run well to the benefit of the residents and staff, however the manager has not been approved by the Commission so the home does not have a registered manager. EVIDENCE: Mrs Lyn Thompson was appointed as manager of the home following the last key inspection, which took place in October 2007. The previous manager left voluntarily. Mrs Thompson has obtained an application for her approval as the Registered manager of the home but has not yet completed it. The manager was advised to complete and forward onto the Commission her application to ensure that the home has a registered manager as soon as possible. All the staff spoken with during the visit said that the home is run well. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 24 As Part of the homes quality assurance process and in accordance with Regulation 26 of the Care Homes Regulations 2001 Amended (2004), a representative for the home visits the premises monthly. They interview people and inspect the environment. Reports are written following the visits and kept at the home. The policy and procedure check list completed as part of the pre-inspection questionnaire showed that health and safety policies and procedures relating to the environment are available at the home and that they were all reviewed in March 2007. Discussion with staff and examination of records showed that they have undertaken training in areas of health and safety including: First aid, fire awareness, infection control and manual handling. Records showed that these are updated at the required intervals. A handbook containing the policies and procedures as available in the office. A number of certificates in safe working practice areas and equipment were examined. These were current for fire safety, gas, and portable appliances. Discussion with staff and examination of records showed that they have undertaken training in areas of health and safety including first aid, fire awareness, infection control and manual handling. Refresher courses in some of these subjects are detailed in the pre-inspection questionnaire as future training planned. Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 25 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 1 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 2 X 2 X 3 X X 1 X Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation 13(2) Requirement Safe medication procedures must be carried out to ensure the health and safety of residents. The rear garden must be appropriately maintained and made safe for the use residents. All parts of the home must be kept in a good state of repair externally and internally to ensure the health, safety, comfort and dignity of the residents. The manager must ensure that she completes and puts forward her application to the Commission for approval of registered manager of the home. Timescale for action 09/04/07 2. 3. YA24 23(2)(o) 23(2)(b) 02/06/07 02/07/07 YA24 4. YA38 9(1)(2) 02/05/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Southport Road, 119 DS0000005278.V332855.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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