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Inspection on 28/02/06 for Thingwall Lane, 28

Also see our care home review for Thingwall Lane, 28 for more information

This inspection was carried out on 28th February 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 3 statutory requirements (actions the home must comply with) as a result of this inspection.

What follows are excerpts from this inspection report. For more information read the full report on the next tab.

What the care home does well

The service tries to empower the service users to live as independent a lifestyle as possible. The staff team encourages both service users to reach their full potential. Although verbal communication is difficult both service users attend all team meetings, which helps to make them feel involved in the home. Medications are managed safely by the home. The manager follows good practise by ensuring staff receive follow up training to ensure they fully understand what to do. This means that the risk of a mistake occurring is reduced. Staff have written information about when to give certain medication. This helps to ensure that service users receive the right medication when they need it. The service is open about receiving complaints and has produced literature for staff, service users and representatives should they wish to raise a concern. This shows a willingness to listen to the views of others. The service has robust recruitment procedures, which means that the staff employed, are fit and safe to support vulnerable people. All new staff receive a thorough induction in to their role and into the home.

What has improved since the last inspection?

Documentation relating to fire prevention has been reviewed which helps to ensure that the home is safe.Despite the service users residing at the home for a long time staff continue to try to source new and interesting activities for them. This work has continued since the last inspection. One service user in particular has become more sociable through this. Labels of favourite foods have been laminated to show to service users. This helps them to make choices about which food they would like to eat.

What the care home could do better:

A requirement was made following the last inspection that identified works which needed doing to the tiles of the bathroom and the kitchen and the bathroom floor. It was identified during this inspection that the timescale has past and this work had not been carried out This must be addressed. The manager is registered with the CSCI to manage the home. A requirement of the law is that current information is kept about the manager to prove that she is fit and safe to undertake her duties. At one time this was kept in the home and therefore was available for inspection purposes however it was identified during this visit that most of the information has been returned to head office. This must be rectified. The organisation CIC no longer has a quality assurance department. The manager appeared keen to develop her own which was` specific to the home by surveying service users families/representatives/staff and visiting health professionals. This must be carried through.

CARE HOME ADULTS 18-65 Thingwall Lane, 28 28 Thingwall Lane Liverpool Merseyside L14 7NX Lead Inspector Hjuy90fvg78;’trejgd6Unannounced Inspection 28th February 2006 10:00 Thingwall Lane, 28 DS0000021487.V283726.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 Thingwall Lane, 28 DS0000021487.V283726.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. Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Thingwall Lane, 28 Address 28 Thingwall Lane Liverpool Merseyside L14 7NX 0151-228-0824 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.c-i-c.co.uk. Community Integrated Care Miss Suzanne Walton Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service Users to Include up to 2 (LD) The service should at all times have a suitably qualified and experienced manager who has been approved by the Commission for Social Care Inspection Date of last inspection Brief Description of the Service: 28 Thingwall lane is operated by the organisation C.I.C. Maritime Housing own the building and act in the capacity of Landlord. The service provides support and care to two service users with severe learning disabilities and challenging behaviour. The home is situated on the border of the borough of Knowsley and Liverpool. It is within easy reach of a local esplanade of shops and local pubs. The home is domestic in character and fits in well to the surrounding community. Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The purpose of the visit was to focus on the core minimum standards, which were not assessed during the last inspection in December 2006. For a full overview of the service the reader should refer to both reports. Both service users were away on an outing on the day of the visit. Therefore discussions were only held with the manager. A variety of documentation was viewed which is referred to in the evidence section of the report. The visit lasted two hours. What the service does well: What has improved since the last inspection? Documentation relating to fire prevention has been reviewed which helps to ensure that the home is safe. Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 6 Despite the service users residing at the home for a long time staff continue to try to source new and interesting activities for them. This work has continued since the last inspection. One service user in particular has become more sociable through this. Labels of favourite foods have been laminated to show to service users. This helps them to make choices about which food they would like to eat. 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. Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: No standards were assessed from this section on this occasion. Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): EVIDENCE: No standards wee assessed from this section on this occasion. Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 10 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): 16 Staff support and value service user rights EVIDENCE: A discussion was held with the manager and two essential lifestyle plans were viewed. Both service users have and are supported to use front door keys. Both service users are involved in light domestic chores according to their ability. Both attend house meetings. One service user has a bus pass and is supported to use public transport. Both plans contained a copy of the document” your choice” consultation paper. House policy is that all parts of the home are unrestricted except for service users bedrooms. Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 11 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): 20 Medications are managed safely within the home. EVIDENCE: Medication administration records (MARS), staff training records and essential lifestyle plans were viewed and a discussion was held with the manager. Staff are signing for all medication given. Instructions on MARS were found to be clear. Written trigger signs are provided for staff to follow for the administration of PRN medication. A written profile is available for each service user which details their prescribed medication, what its for and when and how it should be given. Records showed that stock checks are undertaken as a form of auditing. A list of staff signatures was available for referral. All medication was being stored in a locked wall mounted cupboard. Each medication file had a photograph of the service user attached. Staff records showed that staff receive training on the administration of medication during their induction period. The manager showed a booklet, which is used as a follow up to ensure that the training has been understood. Thingwall Lane, 28 DS0000021487.V283726.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 Service users and Staff have information on how to complain. EVIDENCE: A discussion was held with the manager. Both essential lifestyle plans were viewed. The manager confirmed that no complaints have been received about the service. The inspector can confirm that no complaints have been made to CSCI against the service. Each essential lifestyle plan has a copy of C.I.C s complaint procedure within it. This contains details of how to complain to CSCI. Thingwall Lane, 28 DS0000021487.V283726.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): EVIDENCE: No standards were assessed on this occasion however compliance with a requirement regarding works to the bathroom floor and bathroom and kitchen tiles were discussed with the manager. It was stated that this requirement has not been addressed due to breakdown in communication. Thingwall Lane, 28 DS0000021487.V283726.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): 32,34,35 Service users receive care from staff who know them well and have had training to meet their needs. Service users are protected by the companies’ recruitment procedures. EVIDENCE: Staff files and training records were viewed as well as duty rosters. A discussion was held with the manager. The duty rota showed that a permanent team of staff are employed. Each service user almost has their own team of staff. A mixture of genders is employed so service users receive personal care from the same sex Five of the eight staff employed have achieved a level two in care award. Another two staff are commencing this award next month. Two files for new staff members were viewed. These contained all the required documentation as advised by the Care Home regulations 2001. Each member of staff undertakes a three-day foundation course away from the home. A four day induction course is undertaken within the home also. Topics covered during these periods were viewed and were found to be relevant to a support workers role. The manager confirmed that staff receive a copy of the General Social Care Councils Code of Conduct. Thingwall Lane, 28 DS0000021487.V283726.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 39 Not all information was available to ensure that manager is “fit to manage” therefore no judgement could be drawn. The organisation no longer consults with service users about their views. EVIDENCE: The manager discussed her staff file. The inspector can confirm that during previous inspection the managers personal information i.e. references etc where available to prove that she is fit to manage. During this visit it was identified that much of this information was missing. The manager stated that this had been returned to the organisations head office as requested. The manager stated that the organisation no longer has a quality assurance department. The manager appeared enthusiastic about the idea of developing quality assurance systems for 28 Thing wall lane when the subject was discussed with her. T Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 16 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 X 2 X 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 X ENVIRONMENT Standard No Score 24 X 25 X 26 X 27 X 28 X 29 X 30 X STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score X X X X X LIFESTYLES Standard No Score 11 X 12 X 13 X 14 X 15 X 16 3 17 X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 x 2 X 1 X X X X Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 17 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 YA30 Regulation 23(2)(b) 16 (2)(k) Requirement The manager must ensure that maritime housing address the smell around the toilet in the bathroom by replacing the floor and that the grouting to the wall tiles in the kitchen and bathroom is steam cleaned. The missing bathroom wall tile must also be replaced. 31/01/06OUTSTANDING REQUUIREMENT Timescale for action 30/04/06 2 YA37 3 YA39 The Responsible individual must 30/04/06 ensure that full information is available to assess this standard and to prove the managers fitness. 24(1)(2)(3) The registered persons must 30/06/06 ensure that effective quality assurance is developed for the service. 17(1)(a) RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 18 No. 1 Refer to Standard YA39 Good Practice Recommendations The manager should be supported to carry through her plans to develop quality assurance systems, which are specific to the home. Thingwall Lane, 28 DS0000021487.V283726.R01.S.doc Version 5.1 Page 19 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Thingwall Lane, 28 DS0000021487.V283726.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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