Inspection on 22/02/06 for Tavy Road (11)

This inspection was carried out on 22nd February 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 1 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Tavy Road (11) 31/01/07

Tavy Road (11) 31/08/05

Tavy Road (11) 19/10/04

Tavy Road (11) 24/05/04

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

CARE HOME ADULTS 18-65 Tavy Road (11) 11 Tavy Road Anfield Liverpool Merseyside L6 2PN Lead Inspector Peter Cresswell Unannounced Inspection 22nd February 2006 11:45 Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Tavy Road (11) Address 11 Tavy Road Anfield Liverpool Merseyside L6 2PN 0151 263 5993 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) Personal Service Society Mrs Valerie Hamilton Care Home 3 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (3) of places Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. Three (3) persons with mental disorder (MD) excluding learning disability or dementia. May from time to time admit persons over the age of 65 31st August 2005 Date of last inspection Brief Description of the Service: Tavy Road is a bungalow which is home to two older people with mental health problems. Both of the present service users are over the age of 65 and this is reflected in the home’s registration conditions. A third longstanding resident died recently and that vacancy has not yet been filled. Tavy Road is run by PSS, a major voluntary organisation based in Liverpool, and the building itself is owned by Cosmopolitan Housing - a housing association. The present manager was registered last year. 11 Tavy Road was built in 2001 and is part of a small estate of new properties in Anfield, close to bus routes and local facilities. All of the residents have single bedrooms and they share a dining kitchen, lounge, garden and bathroom. The furnishings and decoration are high quality and the bungalow is well maintained. The home is fully accessible to wheelchair users. The existing residents have lived at Tavy Road ever since it was opened and indeed the house was built with their needs in mind. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and was dealt with by the support worker who was on duty. The inspector spoke to both of the residents and the support worker; he also examined documents including care plans, medication records, training records and fire safety. The inspector also spoke briefly by telephone to the Registered Manager the day after the inspection to clarify one or two minor points. What the service does well: 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. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 6 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 Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 7 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. The owners’ procedures are designed to ensure that prospective residents are thoroughly assessed before admission, protecting the interests both of the new and existing residents. EVIDENCE: The Statement of Purpose needs to be updated to refer to the Commission for Social Care Inspection rather than its predecessor body, the NCSC. The owners, PSS, have well established procedures for assessing prospective residents and great care is being taken before the existing vacancy is filled. The Registered Manager is aware that it is essential that the new resident is compatible with the existing residents, both of whom have lived at Tavy Road since it was built and were close to the resident who died. The manager said that some possible candidates for the vacancy are being considered and they will visit the home and meet the current residents before any decision is made. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 8 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, 10. Excellent care planning and daily reports provide staff with the information they need in order to care for the residents. EVIDENCE: Each resident has a care plan, an Assessment of Activities of Living and Risk Assessments. The documents are comprehensive, giving staff the information they need to enable them to provide appropriate care in an accessible format. The assessments are reviewed every year and the care plans reviewed every eight weeks. The service users attend and take part in the reviews if they want to do so. Recent reviews set out specific goals for individual residents, such as saving up for a trip to Chester races. Risk assessments are reviewed annually and cover all of the service users’ activities, including trips out. Staff make thorough daily notes on the residents’ welfare, closely linked to elements of the care plan, and a key worker makes a weekly summary. Staff talk to the residents about all aspects of life in the home. One of the service users takes responsible risks in that he goes out on his own to local facilities. Staff make sure that they know where he is. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 9 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): 11, 12, 13, 14, 15, 16, 17. The home supports and provides appropriate activities that meet the individual needs and likes of the residents. The home provides a healthy diet that meets the residents’ tastes and nutritional needs. EVIDENCE: The residents have different interests and are encouraged to pursue them to the best of their ability and inclination. Activities they take part in include going shopping, going to a to race meeting, and having lunch in local pubs. One resident has expressed an interest in going to church and staff will arrange this. One of the residents helps with the shopping and carries out some small errands on his own. Last year this resident went on a highly enjoyable holiday to Llandudno with two members of staff and is hoping to go again this summer. The other resident uses a wheelchair and has started to go out with staff to the shops and for local walks, which she greatly enjoys. Both residents are on the electoral register and have the right to a postal vote. The residents choose the meals they would like and staff ensure that their preferences are respected and that their diet is healthy and suitable. A record is kept of the meals prepared. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 10 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, 21. Staff have a good understanding of the service users’ needs and provide effective support accordingly. Procedures for the administration of medication are sound and protect the safety of the service users. Illness and death are handled with respect. EVIDENCE: Staff provide personal care in a dignified and sensitive manner and details of how care should be provided is contained in care plans. All of the residents are registered with local doctors and receive all of the community and specialist heath care that they need. A chiropodist visits the home regularly. None of the service users administer their own medication and it is administered by staff using a monitored dosage system, with tablets dispensed from blister packs prepared by the pharmacist. Medication is accurately recorded on Medication Administration Record sheets. Where medication is not included in the MDS it would be helpful to record the amount of medication received on the MAR sheets. A much loved, longstanding resident died recently and one of the other residents and the member of staff talked to the inspector about how much he was missed. Staff, both of the residents and many friends attended the Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 11 funeral and it was evident that this very sad episode was dealt with in a sensitive and caring manner. The Registered Manager said that it is planned to bury the ashes in the garden and plant a rose tree in the resident’s memory. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 12 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. The home has satisfactory complaints and abuse procedures to protect the interests of the service users. EVIDENCE: The home had on display a PSS complaints leaflet which explains how to make a complaint and how to contact the Commission for Social Care Inspection if necessary. No complaints have been received since the last inspection. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 13 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, 25, 26, 27, 28, 29, 30. Tavy Road provides a comfortable, secure and homely environment for its service users. EVIDENCE: 11 Tavy Road is a bungalow and is fully accessible to its service users. The home is clean and well decorated and a cleaning rota was on display in the small office/sleep-in room. The building’s owners, Cosmopolitan Housing, deal with maintenance matters and there were no outstanding repairs at the time of the inspection. Each resident has a spacious and comfortable bedroom and the vacant room will be redecorated to the taste of the new resident when that time comes. The house is well furnished and a resident who has mobility restrictions has a specialised armchair in the lounge. The same resident has a specialist bed with built in bed rails which are fitted with padded ‘bumpers’. Each service user has a small safe in their room to secure any personal items. The home has an assisted bath and a shower. The service users eat their meals in the bright, comfortable dining room /kitchen which is to be redecorated shortly. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 14 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, 33, 35, 36. Staff supervision and training procedures help to ensure that well trained staff are available to meet the needs of the residents. EVIDENCE: The staff team is very stable, experienced and committed to the care of this small resident group. Two members of staff have NVQ2 and one member of staff is currently studying for one. Recent staff training has included Confidentiality, Manual Handling and ‘Working with older people’. PSS has an extensive training programme and staff are encouraged to apply for courses as they are advertised. The training schedule for March was on display in the office. The home is adequately staffed and additional staff are provided if residents are going out and need to be accompanied. If additional or relief staff are needed they come from PSS’s own bank and they know the residents. The home does not use agency staff. Staff receive quarterly supervision from the Registered Manager who in turn is supervised by the Project Manager. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 15 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, 38, 41, 42. The home is effectively managed and safety procedures are observed, ensuring that there is a safe environment for the service users. Regular visits by senior managers help to ensure that standards are maintained in the interests of the service users, but reports of these visits are not forwarded to the Commission for Social Care Inspection. EVIDENCE: The Registered Manager now has an NVQ4. The atmosphere in 11 Tavy Road is relaxed, informal and welcoming and the manager and staff go to great lengths to make sure that residents are able to express their views about the running of the home. The Deputy Project Manager and other managers visit the home regularly to speak to the service users and staff and to check on standards in the home. However, no reports of monthly unannounced visits have recently been submitted to the Commission for Social Care Inspection as required by Regulation 26. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 16 Fire safety records and safety certificates were properly kept and up to date. There was some evidence that fridge and freezer temperatures are checked but they were not recorded. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 17 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 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 3 28 3 29 3 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 X 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 4 X 3 X X 3 2 2 Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 18 Are there any outstanding requirements from the last inspection? No 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 YA43 Regulation 26 Requirement The Registered Person shall arrange for reports of visits made on behalf of the organisation to be forwarded to the Commission for Social Care Inspection each month. Timescale for action 01/03/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA42 Good Practice Recommendations Staff should check and record fridge and freezer temperatures every day. Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 19 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 Tavy Road (11) DS0000025150.V284180.R01.S.doc Version 5.1 Page 20 - 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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