Inspection on 18/10/06 for Spinal Unit Action Group The

This inspection was carried out on 18th October 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. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Spinal Unit Action Group The 10/05/07

Spinal Unit Action Group The 09/02/06

Spinal Unit Action Group The 17/11/05

Spinal Unit Action Group The 30/06/04

Similar services:

Ruskin Lodge

Dystlegh Grange

The Good Companions

Springfield Cottage

Cuerden Grange Rest Home

Cornmill Nursing Home

Vitalise Sandpipers Centre

Sue Ryder Care Birchley Hall

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

CARE HOME ADULTS 18-65 Spinal Unit Action Group The 6 Weld Road Birkdale Southport Merseyside PR8 2AZ Lead Inspector Ms Lorraine Farrar Unannounced Inspection 18th October 13:35 Spinal Unit Action Group The DS0000005364.V304807.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 Spinal Unit Action Group The DS0000005364.V304807.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. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Spinal Unit Action Group The Address 6 Weld Road Birkdale Southport Merseyside PR8 2AZ 01704 563633 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) The Spinal Unit Action Group Mr Graham Sharpe Care Home 12 Category(ies) of Physical disability (12) registration, with number of places Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. Service users to include up to 12 PD Date of last inspection 9th February 2006 Brief Description of the Service: The Spinal Unit Action Group known as SUAG is registered to provide accommodation and support for up to 12 adults who have a disability associated with spinal injuries. The Home is run by a charity and managed by Mr Graham Sharpe. Situated close to Birkdale village in Southport, SUAG is well located for getting to local shops, facilities and public transport. The Building is a large Victorian property, which, has been converted to provide 12 single bedrooms and ample communal space for Residents. Outside there is parking available and a large, well maintained garden. A full range of aids and adaptations are provided within the home. There are Staff working in the home 24 hours a day to provide support to Residents when needed. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Information for this inspection was gathered in a number of different ways. This included an unannounced site visit where time was spent reading records, meeting with Residents and Staff, observing life in the home and looking at the building. ‘Case tracking’ was used as part of the visit. This involves looking at the support a person gets from the home including their care plans, medication, money and bedroom. Time is also spent meeting with the Residents and with Staff about how they meet the person’s needs. Case tracking was used to look at life in the home for three of the people staying there. Discussion took place with 7 Residents and 5 members of Staff. In addition comment cards were sent out before the visit, 4 Resident’s returned cards and their views are included within this report. The Manager was given the opportunity to provide information about the service prior to the inspection by filling in a questionnaire. This information and any other relevant information the CSCI has received about the home, since the last full inspection in February 2006, is included within this report. Fees for living in the home per week are from £472 to £517. What the service does well: SUAG provides a specialist service for people who have had a spinal injury. Staff are knowledgeable and skilled in providing personal and healthcare to meet Residents needs. All Residents spoken with stated their satisfaction with the home, with one Resident stating “its as near perfect as you can get” and another, “it’s a good place, better than I thought it would be”. Residents are independent in running their lives and this is fully supported by the Staff Team. Residents make their own decisions and explained that Staff will offer advice on health care etc but that the final decisions lies with the Resident. Staff have built good relationships with Residents and are friendlily but respectful of their choices, taking time to chat and to consult with Residents whilst respecting their right to privacy. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 6 This runs through every area of the home. Residents choose when to get up, the type of personal care they want and the time they want it providing. Meals are flexible with plenty of choice and no set times. The home is well located for accessing local amenities and Residents are able to get out and about on their own. There are good aids and adaptations provided to support residents with their mobility and physical needs. 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. Spinal Unit Action Group The DS0000005364.V304807.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 Spinal Unit Action Group The DS0000005364.V304807.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 & 3 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents are provided with sufficient information about the home before they move in. Information is obtained about the person’s needs and choices but is not always readily available. EVIDENCE: The four Residents who completed comment cards all said that they had received enough information about the home before they moved in. They also said that they had been consulted about moving to SUAG. In discussion with a Resident who had recently moved in, he confirmed that he had been to look around the home and had been fully involved in making the decision to move there. The Deputy Manager explained that when someone new is referred to the home, the Spinal Unit at the local hospital completes an assessment, and that the person is fully involved in providing the information. This information along with the visit the person makes to the home, is used to make sure SUAG can meet their needs and choices. A Resident spoken with confirmed that he did discuss his needs with the home before moving in. However no copies of these assessments were on care plans in the home. The plan for a Resident who was staying for a short time did not have an updated assessment of his needs. Although the people living at SUAG can inform Staff of the support they need, the lack of an up-to date assessment may mean that all the support and equipment a person needs is not readily available. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 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): 6,7,8 & 9 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents’ individual needs and choices are identified and met by the home, however the recording of this needs to be further developed. EVIDENCE: In their comment cards and in discussions with Residents they consistently said that they make their own decisions and can do what they want at all times. One Resident explained “we call Residents meetings when we want them” and another “its free and easy, I come and go as I please”. One Resident said that he would like to be involved in the recruiting of new Staff. Basic care plans are in place for Residents, these generally contain assessments of the person’s health care needs. Of the three plans looked at during the visit, none were completely up to date. Two did not contain the dates the assessments were carried out and a third had not been completed with regard to the person’s medical conditions. In discussions with Residents they consistently explained that they dictate the care they want and decide how to spend their time and that Staff always meet their needs and respect Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 10 their choices. However the lack of up to date information in plans could lead to a persons needs not being fully met or identified. Residents explained that Staff work with them to identify risks to their health and explained that they inform Staff when they are going out and if they will be late home so that any unusual occurrences are noted and acted upon. Information about individual risks to Residents is not always recorded in their plan. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 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): 12, 13, 14, 15, 16 & 17 The quality in this outcome area is excellent. This judgement has been made using available evidence, including a visit to this service. Residents are able to lead the lifestyle that they choose with support provided by staff when needed. EVIDENCE: In discussions with Residents it was evident that they make their own choices and Staff respect these. Comments included, “Staff respect your privacy” and “its home from home, I’m very happy here”. During the visit, Residents and their Visitors were in and out throughout the day. Both Residents and Staff explained that Residents are asked to say when they are going out and what time they will be home. However Staff do not ask where they are going and respect their right to a private life. The people living at SUAG go out independently, however there is also a mini bus and holidays and outings are arranged at Residents request. On the day of the visit one Resident was out for a meal with Staff celebrating his birthday. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 12 Residents explained that Visitors can “come whenever you want” and that meal times are not set. This was observed during the visit when only two people were eating their meal in the dining room. The cook explained that everyone is asked daily what they want to eat and if requested meals are put aside for them to eat later. Menus were varied and contained healthy eating options. A Resident explained that they can also ask for meals that are not on the menu, and another described meals as “brilliant, very good indeed”. There is a small kitchen, which equipped to make drinks and snacks, this was seen to be used by visitors throughout the day. During the visit Staff consistently knocked on doors before entering and always consulted with Residents about their wishes, taking time to talk with people and obtain their views. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 13 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, 19 & 20 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents’ personal and healthcare needs are identified and met in partnership with themselves, Staff and healthcare professionals. Further development of record keeping would be of benefit to Residents and Staff. EVIDENCE: A Resident said that he was “well pleased” with the home and got support with personal care on request. He explained that Staff check his skin every day, “they tell you if it’s breaking down, then ask what you want to do about it”. Another Resident confirmed this and explained Staff offer advice, “then its up to me what I do”. All Residents said that Staff respond very quickly to requests for support, with one Resident explaining they get, “24/7 care by people who know what they are doing, it’s built for you”. Individual aids and adaptations are provided to support people with their personal and health care needs. Staff work with health professionals to meet Residents health care needs, including the GP and District Nurse and records show that health emergencies are identified and responded to positively. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 14 However not all records are completed or followed up on. One entry asked staff to monitor a Residents health every 15 minutes. However no further entry was made for several hours when it was noted the Resident had attended hospital, as he was not responding to treatment. In the event that a Resident was unable to verify the support provided, there is not always a clear audit trail of the actions taken by Staff to meet healthcare needs. Staff explained that Residents look after their own medication and two Residents confirmed this. This is good practice and ensures that Residents independence is respected. Medication is kept in the person’s bedroom and a Resident explained he requests help with this when needed. In two bedrooms boxes of tablets were lying around, not locked up, this could be a risk for other Residents, Visitors and Staff. A Resident explained that Staff help him by dispensing the medication from the packet and handing it to him. Staff have not received any training in medication and risk assessments have not be written for Residents looking after their own medication. As Staff are handling medication they should have training in this area to make sure they can recognise side effects and they are dispending it correctly. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 15 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The quality in this outcome area is good. This judgement has been made using available evidence, including a visit to this service. Residents are listened to and any concerns expressed are acted upon by Staff. EVIDENCE: Residents said in their comment cards and in discussion that they know how to complain and who to speak to if they are unhappy. One Resident explained, “The Manager acts quickly if there’s a genuine complaint, he wouldn’t brush it under the carpet”. There are policies and procedures in place for dealing with complaints and adult protection issues and Staff spoken with had an understanding of these and had received some training. No complaints or concerns have been raised about SUAG since the last key inspection of the service. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 16 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 & 30 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. SUAG provides a comfortable, well adapted home for people to live in. EVIDENCE: SUAG is located in a residential area and is close to the town centre, shops, amusements and facilities. Accommodation is provided over three floors with all areas fully accessible via a passenger lift and ramps. Aids and adaptations are provided throughout the home to meet Residents individual needs. These include overhead tracking to use with hosts, purpose built dining tables and shower and bath adaptations. Some rooms have been recently redecorated, the wallpaper in one bedroom was ripped, however the Resident explained that “its down to be done” and that he would choose the décor. All Residents have a single bedroom; these provide enough space for their possessions, adaptations and lifestyle. In addition there is a communal dining room, small kitchen and downstairs snooker / party lounge. Outside there is parking available and a well-maintained, accessible garden. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 17 In their comment cards Residents said that the home is always fresh and clean and this was observed during the site visit. The laundry room was well organised and clean with good infection control procedures in place. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 18 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 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. Residents are supported by an experienced Staff Team who are able to meet their needs and choices. Further development of recruitment practices would be of benefit to all. EVIDENCE: Residents all expressed satisfaction with the Staff Team, one Resident explained, “staff are experienced, they recognise and deal with problems quickly” and another that Staff respect privacy and “they know to wait until we call”. Of the two Staff files looked at one, for a newer member of staff, did not contain copies of references or evidence of a police check. This means that staff could be unsuitable for care work. A Resident explained that all new Staff work with an experienced Staff member and that after a while the Manager, “asks us if we are okay with new staff helping us on their own.” In discussions with Staff and Residents and in observing throughout the visit, it was evident that Staff are skilled in providing support to Residents. It was also evident that they respect Residents rights and work with them. A Resident explained, ““they know to wait until we call” and a member of Staff explained, Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 19 ““It’s a partnership with good working relationships between staff and residents”. Over half the Staff team hold a care qualification and records showed that Staff have training in areas such as moving and handling and a Resident explained, “The carers are well trained with the hoist etc”. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 20 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 & 42 The quality in this outcome area is adequate. This judgement has been made using available evidence, including a visit to this service. The home is safe and operated well, however further development is needed to ensure the quality of the service is monitored. EVIDENCE: Mr Graham Sharpe has been the Manager of the home for many years. He is an experienced Manager with a good knowledge of supporting the people who live there. Residents and Staff spoken with all expressed confidence in the management of the home, with one member of staff explaining they get good support from the Manager and “things are always sorted out” and a Resident explaining the Manager and Deputy “sort it out” if there are any issues. At the last inspection of the home a requirement was given that an annual audit of the service should be carried out. This would help Residents and Staff to identify the areas the service are good at and the areas that could be Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 21 improved. No evidence was available at this inspection that this audit had been carried out. A sample of health and safety records were checked, this included, fire records and gas safety. All were satisfactory and up to date. Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 22 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 3 2 2 3 X 4 3 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 3 25 X 26 3 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 4 33 X 34 1 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 1 4 3 2 X LIFESTYLES Standard No Score 11 X 12 3 13 4 14 3 15 3 16 4 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 1 X X 3 X Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 23 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 YA39 Regulation 26 Requirement The Registered Person must ensure an annual audit of the quality of the service is carried out. This is a previous inspection requirement. The Registered Manager must work with Residents to ensure all care plans are complete, up to date and reviewed. The Registered Person must; Ensure safe storage for medication is provided and used. Ensure a written risk assessment is in place for all Residents who look after their own medication 4. YA20 18(1)(a) The Registered Person must ensure all Staff dealing with Residents medication received training in this area. The Registered Person must audit Staff files to ensure all recruitment checks have been carried out and evidenced. 28/02/07 Timescale for action 28/02/07 2. YA6 15 20/01/07 3. YA20 13(2) 20/12/06 5. YA34 17(2) 20/12/06 Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 24 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard YA2 Good Practice Recommendations The Registered Person should ensure pre-admission assessments are held on Residents care plans and that these are updated for people each time they stay. The Registered Person should explore ways to include Residents in the recruitment of new Staff. The Registered Manager should review record keeping in the home to ensure it provides an adequate audit trail of the actions staff take and support they provide. 2 3 YA8 YA19 Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 25 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 Spinal Unit Action Group The DS0000005364.V304807.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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