Inspection on 31/01/07 for Tavy Road (11)

This inspection was carried out on 31st January 2007.

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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Tavy Road (11) 22/02/06

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 Key Unannounced Inspection 31st January and 1st February 2007 11.30 Tavy Road (11) DS0000025150.V289276.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 Tavy Road (11) DS0000025150.V289276.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. Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 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) www PSS.org.uk 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.V289276.R01.S.doc Version 5.2 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 22nd February 2006 Date of last inspection Brief Description of the Service: Tavy Road is a purpose-built bungalow which is currently home to two people with mental health problems. One of the residents is 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 home is part of PSS’s ‘Bradley’ Scheme of services for people with mental health problems. The present manager was registered in 2005. 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 and has assisted bathing facilities. Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection included an unannounced site visit that was dealt with by the support worker who was on duty. The inspector called again the following day to discuss some issues with the Registered Manager. He spoke to both of the residents and the support worker, examined documents including care plans, medication records, training records and fire safety. 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. The summary of this inspection report can be made available in other formats on request. Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 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.V289276.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5. Quality in this outcome area is excellent. The home’s procedures ensure that prospective residents are thoroughly assessed before admission, protecting the interests both of the new and existing residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Statement of Purpose has been updated to refer to the Commission for Social Care Inspection rather than its predecessor body, the NCSC. There is one outdated copy in the home and this should be removed. A new resident has been admitted to the home since the last inspection, replacing a resident who had lived in Tavy Road since it opened. This was a sensitive task and the new resident was introduced gradually to the home. She paid some day visits, followed by overnight stays and then a trial stay which led to a permanent move. Assessment documents from Merseycare NHS Trust were on the file. She was also assessed by the Bradley Project’s management and the assessment documents formed the basis of the care plan. There is now a further vacancy in the home following the death of another of the original residents. The Registered Manager is following similar procedures to fill this vacancy, though the details of the process will be different in order to meet her particular needs. Care will be taken to make sure that the home can meet the needs of the newcomer and ensure her compatibility with the other residents. Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 Page 8 The Registered Manager had been to visit the prospective resident on the day of the inspector’s second visit. Residents have contracts, copies of which are kept on file. Tavy Road (11) DS0000025150.V289276.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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10. Quality in this outcome area is excellent. Tavy Road’s clear, detailed care plans and daily reports provide staff with the information they need in order to care for the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Each resident has a care plan, an Assessment of Activities of Living and Risk Assessments. The documents are comprehensive and give staff the information they need to enable them to provide appropriate care in an accessible format. The file for the new resident included detailed social and psychiatric histories which painted a full and valuable picture of the resident and her needs. The assessments are reviewed every year and the care plans every eight weeks. The residents attend and take part in the reviews if they want to do so and the major reviews are fully documented. 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 and link them to elements of the care plan. A key worker makes a weekly summary. Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 Page 10 Staff talk to the residents about all aspects of life in the home. One of the residents takes responsible risks by going out on his own to local facilities. Staff make sure that they know where he is at all times. Records are kept securely in the small office/sleep-in room. Tavy Road (11) DS0000025150.V289276.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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15, 16, 17. Quality in this outcome area is excellent. The home supports and provides appropriate activities that meet the individual needs and likes of the residents. The home provides a diet that meets the residents’ tastes and nutritional needs. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The residents have different interests and are encouraged to pursue them to the best of their ability and inclination. Staff accompany and support residents who do not wish to go out alone. They enjoy shopping, going on trips out and having lunch in local pubs, for instance. One of the residents helps with the shopping and carries out some small errands on his own. Both residents went on holiday with support staff last year, one to Llandudno, the other to Blackpool. They both told the inspector how much they enjoyed their holiday. One longstanding, much loved older resident died last year and had spent the last year of her life going out shopping, on trips and to church. She had not Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 Page 12 previously been able to do this for various reasons. Staff said that whilst her death was – obviously - very sad, they believed that she had very much enjoyed the last year of her life and a support worker described vividly how much she had enjoyed her visit to a variety show at the Philharmonic Hall. The residents choose the meals they would like and staff ensure that their preferences are respected and that their diet is suitable and reasonably healthy. On the day of the inspection the residents were enjoying sausage sandwiches for lunch and were going to have braised steak for tea. The diet seemed to include a lot of red meat but fish is available at least once a week and both residents said they enjoyed their meals. A workman was repairing some flagstones in the back garden and one of the residents made sure he was supplied with sausage butties and tea. A record is kept of the meals prepared. The residents help with washing the dishes and the rota is displayed. One of them did the washing up after lunch when the inspector visited. Tavy Road (11) DS0000025150.V289276.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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20, 21. Quality in this outcome area is good. Staff have a good understanding of the residents’ needs and provide effective support accordingly. Procedures for the administration of medication are sound and protect the safety of the residents. Issues around illness and death are handled with respect. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Staff provide any personal care that is needed in a dignified and sensitive manner and details of how such care should be provided are 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. Health appointments and visits are recorded on the residents’ files. Neither of the residents look after 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 to be taken ‘as required’ (PRN) the home should, with the advice of the GP or pharmacist, prepare guidance on the circumstances in which it should be taken. The Registered Manager said that the prescription of one Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 Page 14 PRN painkiller which was no longer used was going to be raised at a review with the resident’s GP in the next few days. Staff, one of the residents and many friends attended the funeral of the resident who died late last year and it was evident that this very sad episode was dealt with sensitively. A requiem mass was held in a local church which the resident had attended with staff. The ashes of one previous resident had been scattered in the garden and a rose bush planted in his memory. Tavy Road (11) DS0000025150.V289276.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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. Quality in this outcome area is good. The home has satisfactory complaints and abuse procedures to protect the interests of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: A PSS complaints leaflet was on display which explains how to make a complaint and how to contact the Commission for Social Care Inspection if necessary. No complaints have been received either by PSS or CSCI since the last inspection. Tavy Road (11) DS0000025150.V289276.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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 27, 28, 29, 30. Quality in this outcome area is good. Tavy Road provides a comfortable, secure and homely environment for its service users. This judgement has been made using available evidence including a visit to this service. EVIDENCE: 11 Tavy Road is a purpose built bungalow which is fully accessible to wheelchair 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 kitchen and the hallway have recently been redecorated. Some uneven paving stones in the back garden were being repaired at the time of the inspection. Each resident has a spacious and comfortable bedroom and the vacant room has been redecorated and refurnished. The bedroom for the new resident was redecorated for her arrival and she said that she had helped to choose the colour scheme and new furniture. The house is well furnished and when a resident with mobility restrictions lived there, suitable aids and adaptations were installed, such as a Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 Page 17 specialised armchair in the lounge and specialist bed with built in bed rails. The new resident will be able to have a bed of her choice. 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 residents eat their meals in the bright, comfortable dining room /kitchen. Plans for a conservatory have foundered but the home has received a small donation which the Registered Manager said that this will be used for a gazebo in the garden. There are also plans to replace the kitchen floor. Tavy Road (11) DS0000025150.V289276.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. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36. Quality in this outcome area is good. Staff supervision and training procedures help to ensure that well trained staff are available to meet the needs of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The staff team is very stable, experienced and committed to the care of this small resident group. There have been no staff changes in the last year but there will be some movement in the near future, with one experienced member of staff moving to another small PSS home. She will, however, maintain her valued links with the residents at Tavy Road by working some weekend shifts. A replacement will be recruited using PSS’s well established procedures. One member of staff and the usual pool relief worker (a PSS employee) have NVQ2; a further member of staff is currently studying for an NVQ and a third is about to start a course. Recent staff training has included Moving and Handling, Food Hygiene, Aggression Management and Health and Safety. PSS has an extensive training programme and staff are encouraged to apply for courses as they are advertised. The current training schedule was on display in the office. The home is adequately staffed and additional staff are Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 Page 19 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. Training issues are discussed during one to one supervision sessions. The supervision schedule was displayed in the office. Tavy Road (11) DS0000025150.V289276.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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38, 39, 40, 42. Quality in this outcome area is excellent. The home is effectively managed and safety procedures are observed, ensuring that there is a safe environment for the residents. Regular visits by senior managers help to ensure that standards are maintained in the interests of the residents. This judgement has been made using available evidence including a visit to this service. EVIDENCE: The Registered Manager has an NVQ4. The atmosphere in 11 Tavy Road is relaxed, informal and welcoming; 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. Notes of the meetings were seen on file. Some reports of managers’ monthly unannounced visits, as required by Regulation 26, have Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 Page 21 been submitted to the Commission for Social Care Inspection. Fire safety records and safety certificates were properly kept and up to date, with the Fire Safety Officer having visited in June 2006. There were two minor errors in the dates of the safety checks and the Registered Manager said she would address this issue. Fridge and freezer temperatures are checked every day. Tavy Road (11) DS0000025150.V289276.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 4 3 3 4 4 5 3 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 3 32 3 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 4 3 4 3 LIFESTYLES Standard No Score 11 x 12 4 13 3 14 4 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 4 4 3 x 3 x Tavy Road (11) DS0000025150.V289276.R01.S.doc Version 5.2 Page 23 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. 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. Refer to Standard YA20 Good Practice Recommendations Where prescribed medication is to be taken ‘as required’ there should be written guidance as to when it should be administered. 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