Inspection on 23/05/06 for Speke Care Home

This inspection was carried out on 23rd May 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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Speke Care Home 30/06/09

Speke Care Home 16/06/08

Speke Care Home 03/07/07

Speke Care Home 25/01/07

Speke Care Home 31/10/05

Speke Care Home 01/07/05

Speke Care Home 26/11/04

Speke Care Home 13/05/04

Speke Care Home 29/01/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Speke Care Home 96-110 Eastern Avenue Liverpool Merseyside L24 2TB Lead Inspector Les Hill Key Unannounced Inspection 23rd May 2006 09:30 X10015.doc Version 1.40 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 Speke Care Home DS0000025180.V289064.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 Older People. 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. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Speke Care Home Address 96-110 Eastern Avenue Liverpool Merseyside L24 2TB 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) 0151 425 2137 Mr Abid Y Chudary Mrs Chand Khurshid Latif Joan Lorraine Vernon Care Home 53 Category(ies) of Old age, not falling within any other category registration, with number (53) of places Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 31st October 2005 Brief Description of the Service: Speke Care Home is registered with CSCI to provide care and support to 53 residents within the category of old age. It was purpose built and is situated in the heart of a residential area in Speke, Liverpool. The home is close to a range of local community amenities including local shopping. There are bus and road links to other parts of Liverpool and North Cheshire. Speke Care home is constructed on two levels with stair and passenger lift access. There are 51 single bedrooms and two that are available for double occupancy. Bedrooms in one wing of the home have an en-suite WC and wash hand-basin. Fees for the home have been listed at £307.50 per week. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection of Speke Care Home took place on Tuesday 23rd May 2006 over a period of 3.5 hours. It involved the examination of some records, a tour of the building, meeting with six residents, discussions with the senior member of staff on duty and with, seven other members of the staff team. The home’s manager was absent from work due to sickness and the deputy manager was absent on her “rest” days. The senior carer on duty was knowledgeable about the home and confident in her dealings with both residents and staff. The inspector is grateful for her time and support in carrying out this inspection of Speke Care Home. The CSCI inspection of the home in October 2005 had reported positively about improvements that had been made. However, the inspector was disappointed to find that standards had not been maintained and this report contains a number of requirements to improve the environment, to improve safety procedures, to tighten up the appointment procedures for staff and to improve staffing levels. What the service does well: What has improved since the last inspection? None of the requirements and recommendations made in the last CSCI report has been introduced. Speke Care Home DS0000025180.V289064.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. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 and 6. Residents are given the information they need to make a choice about the home. EVIDENCE: The home has a statement of purpose in place that contains all of the matters identified in Schedule 1 of the National Minimum Standards, Care Homes for Older people. A service users guide is also in place and during the CSCI inspection of 31st October 2005, a copy was in the rooms of residents who had elected to hold one. A contract between the residents and the homeowner was evidenced on care files seen during the inspection in October 2005. No contracts were evidenced on the day-to-day care files seen during this inspection but the inspector understands that confidential information is maintained separately to the main care planning documentation. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 9 The majority of placements at the home are made from social worker referrals. An examination of five residents care files confirmed that a pre-admission assessment had been undertaken and was included on four of the care files. The fifth file was for an emergency admission and contained a partially completed assessment. It is essential that assessments are in place for each of the residents accommodated at the home so that a decision about the appropriateness of the placement can be made and care plans can be produced to reflect the support they need and how it should be provided. Prospective residents and their families are invited to visit the home and to spend some time there before making a decision to stay. In practice many of the residents are admitted directly from hospital or from their own homes in an emergency situation. A trial stay is supported and the home offers respite care when a place is available. Speke Care Home is not contracted to provide Intermediate Care. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 10 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8, 9 and 10. It is not clear from some of the care files that the individual residents health and personal care needs are being met. EVIDENCE: Care plans were evidenced on three of the five care files examined during the inspection. Those that were in place were of a good standard and provided guidance for staff in their day-to-day work with individuals in the home. Both of the residents whose care files did not contain a plan of care had been admitted for respite support in an emergency situation but one of them had a medical condition that required staff to manage his care and support in specific ways. It is a Requirement of the Care Standards Act 2000, Regulation 15, that after consultation with the resident, staff prepare a written plan of care that is reviewed regularly. The Regulations make no distinction between permanent and temporary stays in a home and therefore a care plan must be created for every resident in Speke Care Home. Notes that care plans had been reviewed were identified on the three complete files. However, the notes often read, “No change” or “Care Plans remain Valid”. It is important to ensure that notes from reviews confirm that the care plan Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 11 has been evaluated and refer to any progress, regression or status quo through a direct reference to the ways in which care is to be delivered. Some of the care files contained a social assessment for the resident. The member of staff assisting the inspector said that she had produced the ones already in place but the home’s activities organiser had now taken responsibility for writing them. Some of the residents have been assessed as needing bed rails. A note confirming their use was identified on some of the files but this wasn’t accompanied by a risk assessment and written confirmation from the resident or their family that bed rails could be put in place. As in the inspection of October 2005 bed rails were being used without the safety “bumpers” provided. The use of bed rails must always be accompanied by a risk assessment and they must always be used with the correct safety “bumpers”. The home is supported by local GP’s and by the district nurses. Continence products and dietary advice are obtained when appropriate. The homeowner funds chiropody support and an optician will make domiciliary visits to the home. Some difficulties have been experienced in arranging for domiciliary dental support. Policies and procedures are in place for the receipt, storage and management of medicines. Staff who administer medicines are provided with training and the pharmacist visits from time to time to offer advice ad support. Most of the tablets are provided in blister packs. The inspector observed the member of staff who was giving out the medicines and confirmed procedures with sample MAR sheets. The procedures would indicate that medicines are being managed appropriately. Two of the residents manage their own medicines. A risk assessment was in place and the inspector spoke with one of the residents who was confident with the arrangements and confirmed that they had a locked drawer in their room where the medicines are kept. Policies and procedures are in place in relation to privacy and dignity. The inspector spoke with five members of staff all of whom expressed their commitment to providing safe and supportive care. Residents who spoke with the inspector also confirmed their appreciation of the support provided by all of the staff in the home. The inspector observed staff talking with residents in a friendly and respectful manner and noted that they knocked on bedroom and bathroom doors before entering. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Residents are helped to exercise choice and control over their lives. EVIDENCE: The home has appointed an activities organiser to work on two days each week. The person appointed has only been in post a short while but staff were complimentary about her input into the social/occupational opportunities for residents. The organiser is keeping a record of the activities offered each day and of the residents who participate. Some of the time is spent in individual support as well as in group activity. The weekly Bingo sessions have been retained, as have the bi-monthly cinema shows. Quizzes, trips out, video afternoons, nail care and make up have been introduced. Some visitors arrived at the home during the inspection and confirmed the home’s claim that they are welcomed at any time. From observation during the inspection and from discussion with some of the residents it is clear that staff encourage residents to make choices about their everyday lives. They can choose what time they get up and what time they go to bed, they have a choice at mealtimes and make choices about how they will spend their day. One of the residents has a talent for drawing and painting and spends a great deal of their time in this way. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 13 Residents told the inspector that the cooks generally write up the day’s menu on a white board in the dining room. Although it had not been completed on the day of this inspection. The cook on duty told the inspector that they respond to the individual requests from residents at breakfast time and provide anything from tea and toast to a full English breakfast. Breakfasts were being served during the inspection and the inspector was able to confirm with residents that they had been served with what they had chosen. At other mealtimes the cooks confirm with residents that they wish to take the main meal on offer, or arrange an alternative where this is rejected. Staff confirmed that bread, biscuits and fillings for sandwiches are available in the evening. Hot and cold drinks are available throughout the day. Residents can choose to take their meals in the dining room or in their own room. Cutlery laid on one of the tables had not been cleaned properly and the inspector asked for it to be changed. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 17 and 18. Policies and procedures are in place to deal with complaints and to protect residents from abuse. EVIDENCE: The home has a complaints policy and procedures in place together with a system for recording the outcomes of any investigation. The procedure is referred to in the statement of purpose and is outlined in the service user guide. The manager reported that no complaints have been received at the home in the past twelve months. No complaints about the home have been made to CSCI. Adult protection policies and procedures are also in place and the home has a copy of the procedures put together by Liverpool City Council. Most staff have recently attended a training event on the Protection of Vulnerable Adults (POVA), which they had found both interesting and useful. All of the residents are listed on the Electoral Register and have the opportunity to vote in local and national elections. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19, 20, 21, 22, 23, 24, 25 and 26. Environmental standards within the home are deteriorating. EVIDENCE: Speke Care Home is a purpose built facility the layout of which is suitable for its stated purpose. 32 of the 51 bedrooms have an en-suite WC and wash hand-basin. Individual bedrooms have been personalised according to the wishes of residents. A large lounge/dining room is located on the ground floor and there is a conservatory that is designated as the resident’s smoking room that leads into the garden. A smaller lounge is located on the first floor. The home is equipped with adequate heating and lighting systems, ventilation and hot water supplies. A resident’s call system, fire detection and emergency lighting are also installed. The CSCI inspection report in October 2005 complimented the home on improvements that had been made to the standards of furnishing and Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 16 decoration in the home. Unfortunately that has not been maintained and the inspector has identified a number of matters that require attention. Wallpaper is peeling from the ceiling in the entrance hallway, in the upstairs lounge and in bedrooms around the home, particularly bedroom 18. Many of the bedroom and bathroom door handles are broken and need to be replaced. Not all of the bedroom doors are fitted with self-closing devices. Bedroom and other doors do not close properly onto their rebated frame or are difficult to open or close, a serious concern in the event of a fire. New doors fitted to the entrance hallway are of a poor quality, parts of the overlap strip have been broken and an electronic keypad fitted to ensure residents with a degree of confusion can be kept safe, does not work. If staff are not based in the office by the front door residents can easily open the lock and walk out of the home. The front door to the home does not fit properly. The back panel of the wardrobe in bedroom 18 has broken away and the unit is not secured to the wall thereby enabling it to be pulled over. The quality of bedroom furniture in most rooms is poor and is showing signs of wear. Plastic garden chairs in the conservatory are not suitable for residents who are unsteady on their feet and residents complained that they were uncomfortable. The conservatory, which had been improved for the previous inspection was, on this occasion, poorly fitted out and unwelcoming. The home’s “stand-aid” was broken. The seat fitted to the hoist in the downstairs bathroom could not be locked into place. The seat to the hoist in another bathroom was missing safety grommets and is a potential hazard for male residents. This has been the subject of a health and safety notice and should be rectified with new grommets or a replacement seat immediately. Shampoo and talcum powder was placed in bathrooms. Residents must have their own toiletries and should not have to use communally shared products. One of the downstairs bathrooms/WC did not have a liquid soap dispenser. The outside garden space was again overgrown and unusable. The quality of the environment in any care homes reflects the values of the organisation and the respect it shows to its residents. The inspector is concerned that Speke Care Home is unable to maintain appropriate standards of decoration and together with matters raised in other sections of this report gives concern about the commitment of the homeowner to providing a quality service. Records of staff working arrangements and discussion with staff working at the home identified that on most occasions there is only one domestic working to maintain the cleanliness of the home. Observations of the standards of cleanliness around the building confirmed that some carpets (particularly in the large lounge) are badly stained and that it is taking some considerable time for Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 17 the domestic to get around the home and to ensure all areas are clean and safe. The Inspector is concerned that this further emphasises the lack of commitment from the homeowner to provide a safe, clean and comfortable environment. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 18 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30 Staffing levels at the home do not take account of the needs of residents. The number of staff with an award at NVQ level 2 confirms a level of competency within the team. EVIDENCE: The CSCI inspection in October 2005 identified that “good staffing levels were being provided at the home”. However, the pre-inspection questionnaire completed prior to this inspection showed that the homeowner had reduced the numbers of care staff on duty each morning by one. Staff on duty at the time of this inspection confirmed that instead of working with a manager plus six care staff they were working with a manager plus five care staff. This reduction in care staff is surprising since at the CSCI inspection in October 2005 the home was carrying a number of resident vacancies whilst during this inspection the home was almost at full capacity. Additionally the levels of need in new residents being admitted have increased. The inspector also found that on many occasions only one domestic is available to clean the home. As the home has 51 bedrooms, bathrooms and WC’s, large communal living spaces and long corridors the level of domestic input is insufficient to maintain a clean and hygienic environment. An additional 1.5 staff are employed to manage the laundry and a domestic is available in the kitchen. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 19 The inspector examined the files for three staff at the home. Each contained an application form and two references. However the confirmation of identity documents (copy of birth certificate and passport) listed in Schedule 4 of the National Minimum Standards, Care Homes for Older People were not held in all of them. Confirmation of CRB clearance is maintained separately for the purpose of confidentiality. Two of the staff had up to date clearances but one had a clearance obtained by a previous employer. No confirmation of POVA clearance was noted on the file of the most recent employee. The home’s manager must ensure that POVA and CRB clearances are obtained before any new members of staff are allowed to work in the home. The home’s manager reported that 19 of the home’s 23 care staff (83 ) have an award at NVQ level 2 or above. Unfortunately one of the qualified staff has since left the home. However, this still represents a good level of commitment from both staff and the home and should be maintained. The home’s manager reported that staff had been provided with training in Dementia, Confidentiality, Principles of Care, Medication Awareness and POVA. Staff confirmed that they had received the training and had found it to be extremely useful. The manager reported that training in first aid (essential 4 day course) and challenging behaviour had been requested with dates to be arranged. Staff told the inspector that they understood all future training had been cancelled for the time being. It is essential that staff be provided with ongoing training that is appropriate to the work they are expected to perform. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 20 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 35, 36, 37 and 38 Recent changes to the ways in which the home is managed and the lack of attention to the environment do not give the impression that the service is run in the best interest of the residents. Fire safety is not given appropriate priority. EVIDENCE: The manager has over four years experience of running the home and has gained the Registered Managers Award. She is also registered with the Commission. At the time of this inspection the manager was absent from work through sickness. The deputy manager was also absent, on her “rest days”, but the inspector was ably assisted throughout the inspection by a senior carer who was knowledgeable and confident in her day-to-day dealings with residents and staff. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 21 Staff knew what was expected of them and got on with their work. Residents who spoke with the inspector said the staff worked very hard and were complimentary about their attitudes and the support they provided. Some of the residents have lived at Speke Care Home for some time and commented on the changes they have experienced, particularly in terms of dependency levels in the resident group. In the inspection report from October 2005 the homeowner was required to introduce a programme of quality assurance taking into account the views of residents, their relatives, staff and professional visitors to the home. The inspector could find no evidence to confirm that this matter had been progressed. References earlier in this report to falling standards in the decoration and fabric of the building, the lack of suitably managed outdoor space and the reduction in staffing levels do not give the impression that the needs of residents are used as the basis for decision taking in the home. With the absence of the manager the inspector was unable to confirm that the arrangements for holding residents monies and paying interest on savings were as reported in the previous inspection report. At that time the inspector was satisfied that resident’s money was being managed appropriately and will consider the same arrangements to be in place for the purpose of this report. The financial accounts of the company that owns Speke Care Home were not examined. The manager reported in the pre-inspection questionnaire that she and the deputy manager had attended a training course on appraisal and supervision. Staff in the home reported that regular one-to-one professional was not yet taking place on a regular basis. No appraisal or supervision notes were located on the staff files seen. The manager reported that all of the policies and procedures listed on the preinspection questionnaire and relevant for a residential care home are in place. The inspector checked some of the procedures and the senior carer confirmed that they are accessible by staff. Policies and procedures should be reviewed on a regular basis to ensure they remain up to date and relevant. The inspector was shown records of hot water testing in resident’s bedrooms and bathrooms. The records indicated that temperatures could vary between 31 and 43 degrees. Standards indicate a temperature of 43 degrees as a safe measure and hot water should be maintained as close to this level as possible. The temperature of hot water in staff rooms and kitchens was higher and this is acceptable. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 22 The fire record book showed that the fire alarm system was not being tested on a weekly basis. The Last three dates recorded were 25.02.06, 04.03.06 and 12.04.06. The last fire drill was recorded on 02.01.05. The last record for staff training was 28.04 05. Fire safety should be one of the highest priorities in any care home. Staff must receive regular, six-monthly; fire awareness update training and the fire alarm system must be checked from a different call point each week. Arrangements must be made to ensure staff and residents know what to do in the event of a fire occurring in the home. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 23 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 2 2 2 2 2 2 2 STAFFING Standard No Score 27 2 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 2 2 X 3 2 2 2 Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 24 Are there any outstanding requirements from the last inspection? Yes 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 OP7 Regulation 15 Requirement The registered manager must ensure that all residents have a plan of care that is available to them and is reviewed. The registered manager must ensure that the use of bed rails is accompanied by a risk assessment signed by the resident/relative and that they are fitted with the appropriate “bumpers”. The registered person must ensure that the home is suitable for purpose, is maintained to a good standard and is free from hazards to the safety of residents and staff. In this report particular attention is drawn to: 1. The poor standards of decoration around the home, particularly, but not entirely, in the entrance hallway, the upstairs lounge and bedroom 18. 2. The overgrown garden. Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 25 Timescale for action 30/06/06 2 OP8 13(4)(c) 23/05/06 3 OP19 23(2) 16(2) 13(4) 31/07/06 3. The standard of bedroom furniture in room 18 (and other rooms around the home). 4. The need to ensure bedroom furniture that can be pulled over is fastened to the wall. 5. The lack of door closures on bedroom doors. 6. The broken handles of doors throughout the home. 7. The failure of some doors to close properly. 8. The broken/poor quality internal doors at the entrance to the home. 9. The broken keypad security entering system. 10. The broken “stand aid”. 11. The broken securing lock on a bath hoist. 12. The unsafe seat on a bath hoist. 13. The unsuitable furniture in the conservatory. This list is not exhaustive. 4 OP27 18 The registered person must, having regard to the size of the care home, the statement of purpose and the number and needs of residents, ensure that at all times suitably qualified, competent and experienced staff are working in such numbers as are appropriate for the health and welfare of residents. The registered manager must ensure that any person DS0000025180.V289064.R01.S.doc 30/06/06 5 OP29 19 31/07/06 Speke Care Home Version 5.1 Page 26 employed to work at the home is “fit” to do so and must ensure that all documents listed in Schedule 4 (6) are kept in the home. CRB and POVA clearances must be obtained and confirmation of the clearance maintained. 6 OP32 12 The homeowner and the registered manager must ensure that the home is conducted so as to make proper provision for the health and welfare of residents including the preparation of care plans and the maintenance of a safe and pleasant environment. A programme of quality assurance should be introduced to gain feedback from residents, visitors, staff and visiting professionals. The registered manager must ensure that staff are appropriately supervised The registered person must ensure that all records specified in Schedule 4 are maintained and kept up to date. The registered person must ensure that persons working at the home and residents are aware of the procedures to be followed in the event of a fire including the procedures for saving life. 31/07/06 7 OP36 18(2) 31/07/06 8 OP37 17 31/07/06 9 OP38 23(4)(e) 31/07/06 Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 27 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 Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 28 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Speke Care Home DS0000025180.V289064.R01.S.doc Version 5.1 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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