Inspection on 17/05/06 for The Hamlets

This inspection was carried out on 17th May 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is (sorry - unknown). 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

The Hamlets 09/11/05

The Hamlets 11/05/05

The Hamlets 25/10/04

The Hamlets 29/04/04

Similar services:

Sunny Bank (P.R.S.) Ltd

Ashwood Court Unit 1

Thornton Lodge

Alfred House Residential Care Home

Barkerhouse Road (123)

Fernhaven

Thames House

Creative Support

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

CARE HOMES FOR OLDER PEOPLE St Michael`s 93 St Michael`s Church Road Liverpool Merseyside L17 7BD Lead Inspector Pat Kearney Key Unannounced Inspection 17th 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 St Michael`s DS0000025185.V288423.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. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service St Michael`s Address 93 St Michael`s Church Road Liverpool Merseyside L17 7BD 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 728 9019 Age Concern Liverpool Care Home 12 Category(ies) of Mental Disorder, excluding learning disability or registration, with number dementia - over 65 years of age (12) of places St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th November 2005 Brief Description of the Service: St Michaels is a single storey purpose built care home providing nursing care for 12 older people with functional mental ill health. The home is situated within a residential area of Aigburth South Liverpool. The property is within walking distance to shops, pubs, Sefton Park and a bus ride from Liverpool city centre and other places of local interest. The increasing frailty of the service users may prohibit independent access to these community facilities. Accommodation at St Michaels includes12 single bedrooms all fitted with wash hand basins. There is a large lounge and dining room. The dining room leads onto a patio area and large walled garden. Registered by Age Concern Liverpool over 11 years ago the establishment was a home for life for the then Health Authority service users. All service users admitted to the care home would have a diagnosis of functional mental illness. However the increasing age and frailty of the service users has seen the focus of care shift from predominately mental health to both mental and physical nursing care. The care practices within the home have adapted to meet the changing needs of the service users. In May 2006 the fees charged at St Michaels were £466.50. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection took place on 17th May 2006 and took place over four hours and was a key inspection. Discussions were held with the service users about their experience of living at St Michaels. Six service users surveys were sent to the home prior to the inspection five were completed with assistance from care staff. The views of health and social care professional who visit the home were sought through questionnaires and telephone calls. A range of documentation was examined this included service users care plans, staff personnel files, Health and safety and maintenance records. A tour of the building took place. Discussions were held with the senior manager Registered Nurse care staff cook and domestic staff about the management and daily working practices of the home. What the service does well: Service users said they” were happy” living at the home and that the staff treated them with dignity and respect. Service users said the food had improved and generally they “always enjoyed their meals.” Service users commented that they are kept informed of any changes at the home this was evident by the fact that service users knew that the manager was absent from the home due to illness. The staff works as a cohesive team to ensure that the service users receive a good standard of care. Staff are aware of the care and support needs of the service users and positive and interactive relationships were observed between service users and staff. Service users needs are met by the number and skill mix of staff who are provided with a range of specialist and mandatory training to ensure the ongoing and changing needs of the service users are met. The senior manager visits the home frequently and is known by her first name by the majority of service users. The standard of décor at St Michaels remains very high and provides a comfortable and pleasant environment for service users to live. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 6 The rigorous system for managing service users finance ensures that the financial interests of service users are protected at all times. What has improved since the last inspection? What they could do better: Attention to detail is needed to ensure that all the recruitment documentation is accurate and ensures that service users are protected at all times. When recovered from her illness the acting manager must reapply to become registered with C.S.C.I. Recognising the work already started to improve the quality and variety of food available to service users which has taken into account their individual choices and preferences. Further work needs to be completed to ensure that the individual dietary needs of service users are identified, recorded and that a well balanced and nutritious diet is available to meet the individual needs of the service users at St Michaels. Improvements needs to be made to the assessment and care planning process to ensure that issues of equality and diversity are explicitly addressed. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 7 A training needs analysis should be completed so that the staff group have an awareness of the issues of equality and diversity and the implication for their practice. 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. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 8 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 St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 9 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): 1,3, and 5 The quality in this outcome area is good. The home’s Statement of Purpose and Service User Guide are well written and detailed providing service users and prospective service users and/or their relatives with details of the services the home provides enabling an informed decision about admission to the home. Service users are only admitted into the home following of a multiagency holistic assessment of their individual needs. Issues of equality and diversity need to be explicitly addressed in the homes pre admission documentation so that the individual and specific needs of all service users admitted. Intermediate care is not provided at this St Michaels. EVIDENCE: St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 10 Both the Statement of Purpose and Service User Guide were reviewed and updated in May 2006. A copy of both documents are placed on the table in the in the entrance hall of the home for service users and visitors to the home to read at any time. Copies of the Service User Guide are in left in the service users bedrooms were appropriate and unless it is contraindicated in the overall care of the service user. A newly admitted service user confirmed that they had seen the Service Users Guide. Service users are able to visit the home several times prior to making the decision to move in. Social care professionals spoken to confirmed that “pre admission visits were a normal part of the admission process and that the number and duration of the visits were tailored to meet the individual needs of the service user”. St Michaels has produced a post admission questionnaire which assesses the experience of the service user during the admission process. A newly admitted service user had a copy of the questionnaire completed and placed on their care plan. The service user had been assisted by staff to complete the questionnaire the service user stated that they felt “very positive “about their move to St Michaels. Individual needs are addressed as part of the admission process. An example of this is that to assist a service user with their transition from their previous supported accommodation to St Michaels. A support worker known to the service user for sometime was still visiting and providing support to the service user to help familiarise them into the local community. This support will be phased out as the service user feels more confident with his new environment and the staff group. A comprehensive and holistic multi agency pre-admission assessment is completed. The acting manager visits the service user and conducts a pre admission assessment. Additional information is provided by other health and social care professionals and all this information is collated and forms a comprehensive pre admission assessment. Every effort is made to involve and engage the service user and or their relatives in the pre assessment process. This multiagency approach ensures that St Michaels is able to meet the individual needs of any service users admitted to the home The most recently admitted service user confirmed that an assessment of their particular needs had been completed and that they had the opportunity to discuss with staff any concerns and worries they might have. They confirmed that “staff are attentive and make time to listen to them” Equality and diversity issues are not explicitly addressed on the homes assessment document although staff spoken to were able to give examples of how these issues were or have been addressed in the past. A review of the St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 11 assessment document should be completed to include particular information how the specific needs of service users will be met in relation to their religion, culture, disability, gender, age and sexuality. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 12 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): 7.8.9.10 and 11. The quality in this outcome area is good. Care plans, risk assessments, daily health records for each service user are up to date and reviewed monthly by the senior nurses in the home. This ensures that the current and changing care needs of the service users are identified and met. Equality and diversity issues need to be explicitly addressed and recorded throughout the care planning process. Service users feel the staff group always treats them with dignity and respect. EVIDENCE: All service users in the home have an individual plan of care which is formulated on admission to the home and reviewed by the senior nurses on a monthly basis. This care plan contains the relevant information as to how individual needs of service users are to be met. The nurse on duty was able to give examples of how equality and diversity needs had been met however, not all issues are explicitly recorded as part of the care planning process. The St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 13 documentation available currently does not contain a section that would identify equality and diversity issues automatically as part of the care planning process. This was discussed with the senior manager and the qualified nurse who agreed that this matter would be addressed. A quarterly multidisciplinary review is held at the home which involves the consultant Psychiatrist, social and health care care professionals, home manager and service users and keyworkers. Surveys completed by health and social care professionals who visit the home all commented that the standard of care provided at the home is good and that the home works in partnership with them. Daily health records are documented for each service user this includes any critical incidences plus any visits from GPs, specialist nurses etc. No service user at the home self medicates, the nurses in the home administer all medications for service users. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). Since the last inspection the medication ordering system has been reviewed and the pharmacist supplying the medication has been changed. Staff to receive their NHS entitlements these visits are recorded in the care plan supports all service users in the home. Service users and healthcare professionals surveyed confirmed that any visits were conducted in the privacy of the service users bedrooms and that if the service users wished to speak to the G.P. in private this was facilitated by the staff group. Questionnaires returned to C.S.C.I indicated that service users are happy with the care provided and that staff are attentive and will contact their doctor if they are unwell. The home has recently recruited a Registered General Nurse recognising the increasing physical frailty of the service users this appointment has enhanced the skill mix of the staff group and the additional knowledge and skills are being shared amongst the whole staff group contributing to the care provided to the service users. Since the last inspection the manager has introduced a funeral planning document which identifies service users and/or their families individual choices and preferences with regard to their funeral arrangements. A thank you letter had been received from a deceased service users’ family thanking the staff for their care and attention during the illness of their family member. They commented that the document outlining the service users preferences had been especially helpful to them in arranging the funeral. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 14 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): 12.13.14.15 The quality in this outcome area is adequate. Service users have choice and flexibility how they spend their day in the home, leisure activities are organised according to their choice and preferences which maintains their interests and mental stimulation. There is currently little community involvement with the home so that the home and service users are not actively engaged in the community in which they live. The meals in this home are reasonable offering variety and catering for individual dietary needs which helps to maintain the service users health and wellbeing. EVIDENCE: All service users spoken to said they are able to exercise choice how they spend their days. The home has open visiting arrangements service users “said that relatives and visitors are made welcome” and invited to stay for a meal if they wanted to. Service users can see visitors in the communal areas or in the privacy of their own bedrooms. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 15 Some of the service users visit the local shops accompanied when necessary by staff members. There was little evidence that the service users are involved with the local community or that community groups visit the home. Service users are offered a choice of food at mealtimes this was evident during the inspection when lunch was being served. The alternatives choices available are usually snack type food soup, sandwiches, beans or egg ,on toast there is currently no alternative full meal provided and the choices available are not recorded on the four weekly menu. There was little recording on the daily record sheet when a service user had only had snack at mealtimes. This was discussed with the nurse on duty and the care staff interviewed they all said that that dietary intake of service users is discussed daily with the cook, nurse and care staff on duty however it is not always recorded. Given the cognitive impairment and mental distress experienced by the service users and that fluctuations in appetite can be an indication of increasing mental ill health dietary intake should be recorded on those service users felt to be at risk. All service users are weighed on a regular basis and the weight is recorded. Recordings of service users weight viewed during the inspection showed that there were no great fluctuations in the service users weight. There has been an improvement on the type and variety of meals served to service users since the last inspection. The cook has discussed with the service users their choices and preferences for their meals. This was confirmed by the majority of service users during the inspection. An increased variety of meals are now offered this has included the addition of curries which service users said “they enjoyed very much”. However one service user had raised the issue of food preferences on a questionnaire they had been asked to complete stating they would like different food served when the service user was asked by the inspector had staff discussed their food preferences they said the issues hadn’t been raised with them. Staff spoken to thought this was due to the service user being recently admitted it is important that dietary needs and preferences are part of pre admission assessment and the care planning process any cultural and religious dietary needs must be identified and recorded and discussed with the staff group to ensure that these needs are met. Specialist medical diets are catered for and advice has been sought from the community dietician which has seen the complex dietary needs of one service being met. Further discussion with the community dietician would ensure that all the meals served to the service users are nutritionally well balanced. Recognising that here have been improvements to the quality variety and choices of food available to service users. The pre inspection questionnaire sent into C.S.CI identified that 11 of the 12 service users resident at the home require help/supervision or prompts to eat their meals. Further attention to the recording of food available both for service users ie menu for the day on St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 16 display in the dining room and alternatives available recorded on the menu sheet available for inspection. Dietary intake needs to be recorded on daily record sheet by nursing and care staff. Further discussion with the community dietician would ensure that all the meals served to the service users are nutritionally well balanced. Work has continued since the last inspection, a core group of staff work with the service users to plan the social and leisure activities. It was evident that the number and frequency of social events have increased at the home. A large board has been hung opposite the lounge identifying activities taking place on that day. A diary records the social events planned. Service users confirmed that they were now “doing lots of nice things”. The home celebrates specific days with a buffet and entertainment examples includes a St Patrick’s Day party and a St George’s Day, and recently Liverpool Football Club winning the F.A. Cup. Preparations were being made as to how the World Cup event would be marked. Service users birthdays are celebrated by a special buffet tea and birthday cake. One service user had been taken to the local theatre to watch a concert which she said was “really enjoyable” St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 17 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 17.18 The quality outcome in this area is good. The home has clear policies and procedures for dealing with complaints and adult protection issues which ensure the safety and welfare of service users. Service users are confident that any complaints raised would be dealt with so ensuring the protection of service users at all times. EVIDENCE: There have been no internal complaints since the last inspection. The home has a robust complaints procedure, which is documented in the service users guide and displayed in the hall on the notice board for service users and visitors to see. Service users surveyed said they knew who to speak if they had any complaints. Those interviewed during the inspection said they were sure that any issues raised would be dealt with. Service users said that all the staff at the home are “kind and caring” A newly admitted service user said they knew about the complaints procedure and would know who to speak to if they wanted to make a complaint they were confident they would be listened to. The care home has up to date information on the Protection of Vulnerable adults, this information is communicated to new employees at their induction course. On the day of the inspection there was evidence that all staff in the home had completed training on protecting vulnerable adults. The senior St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 18 manager present at the inspection informed the inspector that plans were being made for staff to update their adult protection training in the coming months. Staff spoken to demonstrated their knowledge of adult protection issues and the impact on their practice. Staff stated that they would have no hesitation in raising any issues with the manager or senior manager if the issue was not addressed. The senior manager is a frequent visitor to the home and represents Age Concern Liverpool on the Liverpool Multiagency Adult Protection Group. Service users who can manage their personal finance are encouraged to do so. Any money managed on behalf of the service users is recorded signed and audited monthly by Age Concern Liverpool finance department “Spot checks” are also completed at the home on an ad hoc basis again by the organisations finance department. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 19 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 26 The quality in this outcome area is good The standard of decor within this home is good, with evidence of continuing improvements, through maintenance and planning. The home does present as a homely, safe and comfortable environment for the service users EVIDENCE: A programme of routine maintenance is in place to ensure that the home is well maintained and provides a comfortable and pleasant environment to live. All parts of the home are decorated to a high standard. A recent leak from the roof has left a small damp patch in one of the bathrooms. The home has received confirmation from Liverpool Housing Trust who own the building that the painters will be out to redecorate the ceiling. A tour of the building confirmed the standard of hygiene remains very high and there are sufficient laundry facilities to cater for the number of service users living at the home. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 20 Systems are in place to control the spread of infection along with supporting policies and procedures which staff are aware of when barrier nursing a service user. Staff confirmed they had completed training in relation to hygiene and infection control. Service users’ bedrooms have been personalised, and contain pictures, and personal memorabilia. Most service users have televisions and/or D.V.Ds. in their bedrooms. The needs of a particular service user are being met by the replacement of the flooring in the bedroom which will make the room more suitable to meet their needs. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 21 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): 27.28.29.30. The quality in this outcome area is adequate Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. Service users needs are met by the number and skill mix of staff who are provided with a range of specialist and mandatory training to ensure the ongoing and changing needs of the service users are met. The recruitment practice and policies are robust however increased attention must be paid to documentation received as part of any recruitment process to ensure that all the detail required by regulation is recorded so that the health safety and welfare of service users is protected at all times. The staff have a good understanding of the service users support needs. This is evident from the positive relationships, which have been formed between the staff and service users. EVIDENCE: There is always a first level Registered Nurse on duty who is assisted by care staff and ancillary staff. The home has recognised that the service users have an increasing level of physical frailty. Since the last inspection the home has recruited a first level Registered General Nurse to improve the skill mix of the staff group and improve the teams ability to meet the service users needs. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 22 The staff rota submitted prior to the inspection indicated there are sufficient care and ancillary staff on duty to ensure the service users are safe and well cared for. Discussion with the staff confirmed they had sufficient time to carry out their work with the amount of staff on duty at any one time. The majority of the staff group at the home have worked there for a number of years and have a really good knowledge of the service users individual needs and preferences in all areas of their lives. Staff work hard to ensure that the service users receive the best possible care. Service users surveyed and interviewed said that the “ the staff were very caring and attentive”, “they are nice and helpful”, “will do anything for you and always speak kindly to me”, “Pat (the senior manager) visits the home every week and always speaks to us”. The home’s recruitment policy is robust and in accordance with the National Minimum Standards. Staff in the home has an up to date CRB/POVA enhanced certificate, so ensuring the safety of the service users. The original copy of the staff personnel files are kept at Age Concern Liverpool headquarters based in Liverpool city centre. Copies of documentation is kept at the home. During the inspection the personnel file for the last recruited member of staff showed that prior to taking up their post a enhanced C.R.B. had been obtained. However, during the inspection it was observed that a P.OV.A. check had not been recorded on the enhanced certificate. The senior manager took steps to check out this issue with the C.R.B. during the inspection and an additional C.R.B. check has been applied for which included a P.O.V.A. check. There are currently six Registered Nurses working at the home. The acting manager has registered to complete the N.V.Q Level 4 Registered Managers course. Documentation submitted prior to the inspection showed that a range of ongoing specialist training has been completed by the Registered Nurses. Information submitted by the senior manager prior to the inspection indicated that seven of the ten care staff employed at the home have completed the NVQ Level 2 Award the other 3 staff members are in the process of completing the award. Four of the care staff are working towards completing N.V.Q. Level 3. Specialist training for all staff employed at the home is ongoing. Records of all training completed are kept in the staff personnel files. The senior manager informed the inspector that the training schedule for 2006/2007 is in the process of being completed this will include the updating of all mandatory training. Discussion took place with the senior manager regarding the increased use of agency staff at the home in recent months. The increase was to facilitate the St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 23 release of the staff to attend training. The same agency staff are used to maintain consistency of care for the service users. Age Concern Liverpool has a policy that during the recruitment of staff no person is age barred from applying for a vacant post. Applicants are not asked on the application form to disclose their age. The senior manager confirmed that if a person post the current retirement age was appointed a detailed risk assessment would be completed prior to them taking up the post and confirmed that the safety and welfare of the service users would be paramount in any decision. All staff who complete an N.V.Q qualification address issues of equality and diversity as part of the core units. Some of the staff group have attended deaf equality training since the last inspection. Those staff spoken to as part of the inspection demonstrated some knowledge of the issues other staff had limited knowledge of the issues and the implications for their practice. All the staff working at the home would benefit from being able to have access to equality and diversity training in relation to culture religion disability gender age and sexuality so that they fully understand the implications for their practice. The senior manager acknowledged the importance of these issues being explicitly part of the homes philosophy and practice and agreed to discuss the issues with the Age Concern Liverpool training officer who would complete a training skills analysis and how they can facilitate the training needs identified for all the staff group. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 24 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 33 35 and 38. The quality in this outcome area is adequate The acting manager is well supported by senior staff in providing clear leadership at the home which ensures that service users are provided with a good standard of care. Staff morale is high in the care home, resulting in an enthusiastic workforce that works positively with residents to improve their quality of life. Turnover of staff is low. Service users financial interests are safeguarded and protected by the rigorous recording and financial auditing systems which have been implemented at the home The health safety and welfare of service users and staff are safeguarded by the regular safety checks conducted at the home. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 25 EVIDENCE: The Acting Manager is a Registered Mental Nurse with many years experience working with the service user group at the home. The acting manager is currently away from the home due to illness and is expected to be away from the home for a period of approximately three months. C.S.C.I. had received a completed managers application form the week prior to the manager’s absence. This was returned to the senior manager Age Concern Liverpool until the acting manager returns to work when they can resubmit the application. The acting manager provides leadership and direction at the home. Since the last inspection the staff group have been able to develop new skills and the training opportunities for staff have increased. Service users, staff and health and social care professionals spoken to as part of this inspection all commented on the “positive influence and leadership “of the acting manager and how much the home had improved under her leadership. Service users said that it was “a happy home” and that the manager was “lovely and kind”. Arrangements have been made for one of the Registered Mental Nurses to “Act up “in the manager’s absence. The senior manager informed the inspector that she will increase her visits to the to provide additional support. The Registered Nurse has many years experience of working at the home and was very knowledgeable about the service users and management of the home when accompanying the inspector during this inspection. Service users were comfortable to approach him and talk to him when the tour of the building took place. Service users had been informed of the acting managers illness when asked they felt they would continue to be well cared for in her absence. Service users all have their own bank accounts the service users who can manage their own finances are encouraged to do so. Those service users who need support in managing their personal allowances are supported by the staff group. A robust system is in place to record and account for any expenditure. The monthly expenditure sheet is audited by the finance department of Age Concern Liverpool and random spot check audits are also conducted at the home on an ad hoc basis by the finance section. The home’s certificates of insurance and maintenance for machines, fire equipments, lift, hoists were in date and valid. Liverpool housing Trust who own the building are responsible for the ongoing servicing of the gas central heating, electrical wiring certificates, water checks, including compliance with Legionella , copies of documentation that confirms all these checks have been completed to meet the health and safety regulations were available for inspection. St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 26 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 x 2 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 3 10 3 11 3 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 3 x x x x x x 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 x 3 x 3 x x 3 St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 27 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 OP3 Regulation 14 Requirement The registered person is required to ensure that issues of equality and diversity are explicitly addressed in the assessment process. The registered person is required to ensure that issues of equality and diversity are explicitly addressed in the care planning process. The registered person is required to ensure suitably qualified and competent staff are employed at the home and that staff receive training appropriate to the work they are to perform. In this instance that all staff have understanding of issues of equality and diversity and the implications for their practice. A person shall not manage a care home unless he/she has the qualifications skills and experience necessary for managing a care home. On their return to work from illness the acting manager should apply to DS0000025185.V288423.R01.S.doc Timescale for action 01/08/06 2 OP7 15 01/08/06 3 OP30 18 01/09/06 4 OP31 9 01/09/06 St Michael`s Version 5.1 Page 28 C.S.C.I. to become registered. 5 OP29 19 The registered person shall not employ a person to work at the care home unless he has obtained in respect of that person the information and documents specified in Schedule 2 of the Care homes Regulations The responsible person must ensure that all information required by regulation completed on the C.R.B. 01/07/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 29 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 St Michael`s DS0000025185.V288423.R01.S.doc Version 5.1 Page 30 - 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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