Inspection on 31/08/05 for Tavy Road (11)

This inspection was carried out on 31st August 2005.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Tavy Road (11) 31/01/07

Tavy Road (11) 22/02/06

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 Tavy Road Anfield Liverpool L6 2PN Lead Inspector Peter Cresswell Unannounced 31 August 2005 9.00 am st 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 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 Stationary 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 F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Tavy Road Address 11 Tavy Road, Anfield, Liverpool, L6 2PN Telephone number Fax number Email 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 263 5993 Personal Service Society Mrs Valerie Hamilton PC Care home only 3 Category(ies) of MD Mental Disorder - 3 registration, with number of places Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 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 Date of last inspection 19 October 2004 Brief Description of the Service: Tavy Road is a bungalow which is home to three older people with mental health problems. All of the present service users are over the age of 65 and this is reflected in the homes registration conditions. 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 earlier this year and this was her first inspection as the registered manager. 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 F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was carried out at a day’s notice. The inspector toured the home and spoke to all of the service users and staff, including the Registered Manager. He inspected documents, including PSS policies, care plans and fire safety records and also examined medication procedures. 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 F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 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 standard(s) 2, 5. The owners’ assessment procedures would ensure that new service users were appropriately admitted to the home as and when that is needed, protecting the interests both of the new and existing service users. EVIDENCE: Tavy Road was built with the needs of the present group of service users in mind and they were fully assessed before moving in. In the event of a vacancy, PSS’s established procedures for assessing prospective service users would be used. In that event the needs of the existing service users would be a major factor and nobody would be admitted unless they were compatible with the other two. Since the last inspection the owners have been granted a variation to reflect the fact that the existing service users are all over the age of 65. Each service user has an individual written contract on file. Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 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 standard(s) 6, 7, 8, 9, Care planning is excellent, providing staff with the information they need in order to care for the service users. EVIDENCE: Each service user has a care plan, an Assessment of Activities of Living and Risk Assessments. The documents are comprehensive and give staff the information they need, in an accessible format, to enable them to provide the care that is needed. The Assessment is reviewed every year and the care plan reviewed every eight weeks. The service users attend the reviews if they wish and take part as far as they wish or are able. Risk assessments are reviewed annually but should be dated. The risk assessments cover all of the service users’ activities, including trips out. Staff make daily notes on the service users’ welfare and a key worker makes a weekly summary. The care plans are reviewed more fully every eight weeks. Staff talk to the service users about all aspects of life in the home, and they contribute to the best of their ability. One of the service users takes responsible risks in that he goes out on his own to local facilities. Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 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 standard(s) 12, 13, 14, 15, 16, 17 The home supports and provides appropriate activities that meet the individual needs and likes of the service users. The home provides a healthy diet which meets the tastes and nutritional needs of the service users. EVIDENCE: All of the service users have different interests and are encouraged to pursue them to the best of their ability and inclination. Activities they take part in include: reading local history books, going to race meetings, and having lunch in local pubs. One of the service users helps with the shopping and carries out some small errands on his own. This service user had also been on holiday to Llandudno with two members of staff and had enjoyed himself enormously. Another service user chooses to spend all of his time in the building but staff and other service users buy him gifts and treats when they go out. Staff encourage the service users to choose their own food and they all make their views and preferences known. Where necessary, staff provide special diets and make sure that the service users follow them. Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 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 standard(s) 18, 19, 20. Staff have a good understanding of the service users’ needs and provide effective support accordingly. Medication procedures are sound and protect the safety of the service users. 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 service users 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 those who are on medication have it 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. If homely remedies are needed then the manager seeks the advice of the pharmacist and the service user’s GP. Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 Page 11 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 standard(s) 22, 23. The home has satisfactory complaints and abuse procedures to protect the interests of the service users. EVIDENCE: The home has a 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. The whistle blowing policy still does not include details of how to contact the Commission. Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 Page 12 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 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. The manager said that requests for repairs are dealt with promptly. Two of the spacious and comfortable bedrooms had been fitted with laminate style flooring to meet the needs of the service users; the third bedroom is due to have a new carpet laid. The house is well furnished and the Registered Manager has recently bought a new specialised armchair for one of the service users who has mobility problems and chooses to spend a lot of time in the lounge. That service user now has a specialist bed with built in bed rails, replacing the old bed which had separate rails fitted to it. The rails are fitted with padded Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 Page 13 ‘bumpers’. The Registered Manager needs to carry out a new risk assessment in respect of this bed. 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 a bright, comfortable dining room/kitchen. Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35, 36. Staff recruitment, supervision and training procedures help to ensure that well trained staff are available to meet the needs of the service users. EVIDENCE: A long serving and much loved member of staff has died since the last inspection. She had worked with some of the service users for thirteen years and they greatly miss her. Two of the service users attended the funeral. The staff team is very stable and experienced. One new member of staff had started since the last inspection and a CRB check was in place at PSS headquarters. The member of staff had previously been employed as a relief worker and her CRB check was carried out by PSS in September 2003. It would be good practice to carry out a new check, including POVA clearance. One member of staff and a relief worker have NVQ2, one member of staff is currently studying for one and another has applied to start a course. PSS encourages its staff to gain NVQs. Recent staff training has included Manual Handling, Protection of Vulnerable Adults and Food Hygiene. PSS has an extensive training programme and staff are encouraged to apply for courses as they are advertised. Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 Page 15 The home is adequately staffed, with additional staff provided when service users are going out and need to be accompanied. On the day in question, for instance, a care worker was going to Birkenhead with one of the service users. Staff receive regular supervision from the Registered Manager who in turn is supervised by the Project Manager. Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 Page 16 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 39, 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. EVIDENCE: The recently Registered Manager is nearing completion of her NVQ4 qualification. The atmosphere in 11 Tavy Road is relaxed, informal and welcoming and the manager and staff go to great lengths to make sure that the service users 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. Fire safety records and safety certificates were properly kept and up to date. Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 4 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 x x 3 4 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Tavy Road Score 3 3 3 x Standard No 37 38 39 40 41 42 43 Score 3 3 3 x 3 3 x F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 Page 18 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action 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. 2. Refer to Standard 23 34 Good Practice Recommendations The home’s whistle blowing policy should include details on how to pass concerns to the Commission for Social Care Inspection. It would be advisable to carry out a new CRB and POVA check on the member of staff who was formerly a relief worker. Tavy Road F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 Page 19 Commission for Social Care Inspection Liverpool Area Office 3rd Floor, 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 F52 F02 S25150 Tavy Road V246928 310805 Stage 4.doc Version 1.40 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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