Care Home: Belvidere Park, 6

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What the care home does well People are only provided with a service after their needs are assessed and they have been assured these needs will be met. Residents are encouraged to make decisions and take risks as part of living an independent lifestyle. Residents are encouraged to take part in activities of their choice, both inside and outside the home, which promotes stimulation and social inclusion. Personal support is offered to each resident in accordance with their own particular needs and in a way, which ensures their privacy and dignity Staff said: "I always make sure that windows, doors and blinds are shut when assisting a resident with personal care". "It is very important to know and understand the person`s routine and preferences with personal care". Resident`s health care needs are well recorded and monitored to ensure their ongoing good health. The home has a complaint procedure to ensure that people are protected and their views and concerns are listened to and acted upon. Recruitment and training procedures and practices ensure that residents are supported by competent and qualified staff. Staff are appropriately supervised and provided with the required training to ensure they develop within their role and are up to date with current care practices. The home is well managed to the benefit of the residents. Systems, which are in place, ensure that their health, safety and welfare is protected and promoted at all times. Quality assurance systems, which are in place, ensure the standard of the service is regularly monitored, reviewed and improved. The staff spoke highly of the Registered Manager and confirmed she was always available for support and advice. Staff made the following comments about the manager: "The manager is flexible" "The manager is very approachable and considerate" "She is easy to talk to and down to earth" "The manager is caring and very good at her job" What has improved since the last inspection? A resident`s bedroom has been redecorated ensuring their comfort and dignity. All staff has been provided with medication training ensuring residents health and safety. Regular checks are carried out ensuring that medication stock and records are maintained accurately at all times. Since the last inspection the manager of the home Debra Thorpe has been approved and registered by the Commission. The kitchen has been refurbished enhancing the comfort and dignity of residents. Arrangements have been put in place to ensure that meal times are an enjoyable and positive experience for residents. What the care home could do better: All of the information recorded on Medication administration record (MAR) sheets was hand written. Under such circumstances two staff signatures should be obtained following completion of these record sheets to ensure the accuracy of the information. The designated smoking area and facility for disposing cigarette stumps should be relocated to prevent staff from smoking on view of the neighbours, visitors and other members of the public, this is out of respect for the residents that do not smoke and whose home it is. CARE HOME ADULTS 18-65 Belvidere Park, 6 6 Belvidere Park Crosby Liverpool Merseyside L23 0SP Lead Inspector Mrs Janet Marshall Key Unannounced Inspection 23rd October 2007 1:00 Belvidere Park, 6 DS0000005248.V343528.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 Belvidere Park, 6 DS0000005248.V343528.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. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Belvidere Park, 6 Address 6 Belvidere Park Crosby Liverpool Merseyside L23 0SP 0151 284 0023 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) Expect Limited Mr Michael James Geddes Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 3 LD. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 15th August 2006 Date of last inspection Brief Description of the Service: 6 Belvidere Park is a care home registered for three people with a learning disability. The registered provider for this home is Expect, formerly known as Sefton Support Services. This organisation is in the voluntary sector and is a registered charity. The property is owned by Liverpool Housing Trust. The home is located in a residential area in Crosby. The house is in keeping with other properties in the area and is indistinguishable as a residential care home. The home is within walking distance of local shops and Crosby village shopping centre is near by. The home is a large five bed roomed house with two reception rooms and good sized gardens. The home provides two staff 24 hours per day and operates on the principle of ordinary community living. It costs £318 per week to live at the home. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was a key inspection. The Commission considers 22 standards for Care Homes for Adults as Key Standards, which have to be inspected during a Key Inspection. The report has been put together using information gathered from a number of sources including information that the commission have received about the service since the last inspection and details provided in the Annual Quality Assurance Assessment (AQAA). The AQAA, which is in two parts, a selfassessment and dataset, has replaced the pre-inspection questionnaire. The document, which was sent out to, the service was completed and returned to the commission before the site visit took place. A number of surveys were sent out to people as part of the inspection but none of them were returned. The inspection also involved an unannounced visit to the home (site visit). Records that were examined, staff comments and observations made during the visit have also been used as evidence for the report. All the residents that live at the home have limited verbal communication skills so were unable to express their views and opinions about the service. However, a number of residents were case tracked. This process involved talking to staff, looking at the environment and a selection of residents records such as assessments, care plans and daily notes to get an idea about peoples experiences and to find out if they are receiving the care and support that they need and which have been agreed by their representatives. The manager was not on duty at the time of the inspection staff that were on duty assisted and were very helpful. What the service does well: People are only provided with a service after their needs are assessed and they have been assured these needs will be met. Residents are encouraged to make decisions and take risks as part of living an independent lifestyle. Residents are encouraged to take part in activities of their choice, both inside and outside the home, which promotes stimulation and social inclusion. Personal support is offered to each resident in accordance with their own particular needs and in a way, which ensures their privacy and dignity Staff said: “I always make sure that windows, doors and blinds are shut when assisting a resident with personal care”. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 6 “It is very important to know and understand the person’s routine and preferences with personal care”. Resident’s health care needs are well recorded and monitored to ensure their ongoing good health. The home has a complaint procedure to ensure that people are protected and their views and concerns are listened to and acted upon. Recruitment and training procedures and practices ensure that residents are supported by competent and qualified staff. Staff are appropriately supervised and provided with the required training to ensure they develop within their role and are up to date with current care practices. The home is well managed to the benefit of the residents. Systems, which are in place, ensure that their health, safety and welfare is protected and promoted at all times. Quality assurance systems, which are in place, ensure the standard of the service is regularly monitored, reviewed and improved. The staff spoke highly of the Registered Manager and confirmed she was always available for support and advice. Staff made the following comments about the manager: “The manager is flexible” “The manager is very approachable and considerate” “She is easy to talk to and down to earth” “The manager is caring and very good at her job” What has improved since the last inspection? A resident’s bedroom has been redecorated ensuring their comfort and dignity. All staff has been provided with medication training ensuring residents health and safety. Regular checks are carried out ensuring that medication stock and records are maintained accurately at all times. Since the last inspection the manager of the home Debra Thorpe has been approved and registered by the Commission. The kitchen has been refurbished enhancing the comfort and dignity of residents. Arrangements have been put in place to ensure that meal times are an enjoyable and positive experience for residents. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 7 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. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 8 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 Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 9 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): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Detailed assessments are obtained prior to admitting new residents to decide if their needs can be met at the home. EVIDENCE: There have been no new residents placed at the home since the last inspection. The AQAA showed that there are clear policies and procedures available at the home, which aims to ensure that people would only be admitted following a full and proper assessment of their needs to be sure that they can be met at the home. The AQAA described in good detail the procedures that would be followed for assessing and admitting a new resident. A persons care need requirements would be assessed by a qualified person representing the home. Other information about their needs would also be obtained from relevant health and social care professionals. This information is required to ensure staff have the information they need on how to provide the right care and support. The staff spoken to during the visit confirmed they had access to this information. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 10 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 & 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Person centred plans provide staff with the information that they need to enable residents to life independent and safe lives. EVIDENCE: Each resident had an individual plan of care, which was kept, securely in the home to ensure confidentiality of the individual. The plans have recently been developed using a new person centred planning format recently introduced to the home. The new person centred care planning approach differs from the format previously used in that it enables people to have more choice and control over their own lives. Two plans were looked at in detail as part of the case tracking process. They covered all aspects of each person’s personal and social support such personal care, independent living skills, accessing the community, relationships and financial needs. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 11 The plans cover in detail things such as what is important to the person, what they are good at doing, what they like and dislike, what they need help with and what they want to happen with their lives. Communication charts are also a part of each persons plan. These are particularly important because all of the residents have limited verbal communication skills. The charts show staff how people communicate, what it means and how they should respond. This information enables staff to support and encouraged residents to make decisions about their lives in order for them to maintain maximum independence. Staff demonstrated an understanding of how to ensure service users rights are promoted and how limitations are only put in place for their safety and welfare. Residents’ personal files and discussion with staff showed that independent advocates are consulted when necessary. Some residents present with challenging behaviour. Staff are trained on how to support and manage residents when they may become verbally or physically aggressive. The person centred plans included guidance about how staff should support the person in a positive way with their behaviour. The plans and associated documentation, which were viewed, showed that have recently been reviewed and updated with the involvement of significant people such as residents’ family, advocates, support staff and the homes management team. Residents are encouraged to take responsible risks, a range of risk assessments, which have been carried out, ensure their independence is promoted and they are protected from the risk of harm. The assessments clearly described the action that staff must take to minimise the risk of harm. A selection of risk assessments were viewed and showed that they are reviewed and updated at regular intervals. Staff have completed training in relation to risk assessment and how to keep themselves and the service users safe from harm. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 12 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, 15, 16 & 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are given appropriate opportunities to live the kind of lives that they prefer. EVIDENCE: None of the residents are currently involved in any employment, training or educational programmes. Their social care needs are assessed and a range of activities is provided inside and outside the home. This prevents the residents from becoming bored and isolated and ensures stimulation and involvement in the local and wider community. The activities that residents are involved in encourage them to establish and maintain relationships for their own personal development. The activities are provided on an individual basis as well as in a group and include day trips out, walks, and pub lunches. All residents attend a social club one evening a week and one resident is supported to attend church Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 13 each Sunday. Residents have use of a shared car which means they can get out and about more easily. A recent trip using the shared car included a trip to Blackpool lights. Staff on duty explained that there are currently very few staff working at the home that have a driving licence which has the potential to restrict opportunities for residents to get out and about in the wider community, this effects one resident in particularly because of their limited mobility. Licensed Drivers should be considered when recruiting staff in the future to maximise lifestyle opportunities for residents. Arrangements are made for residents to go on holiday at least once a year. Residents dietary needs are assessed recorded and met on an individual basis. They are offered a choice of meals, which staff prepare. Were possible residents are involved in the menu planning and weekly shopping to ensure they have meals they enjoy. A requirement was given as part of the last inspection report to provide additional dining space and for mealtime arrangements to be reviewed so that they are flexible to suit each person’s individual needs. This was because at the last inspection visit all residents were sat down together for lunch at a small table in the kitchen. The kitchen appeared cramped and noisy, a member of staff reported one resident is often put off by this and leaves the table before finishing their food. It was felt by staff that the resident would benefit from eating alone. Staff on duty during this inspection explained that meal times arrangements have been changed to suit the individual needs of the residents. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 14 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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health and personal care needs are understood and met to ensure that they maintain good physical and emotional well being. EVIDENCE: Healthcare action plans were part of each persons person centred plan. Staff outlined how they provide different levels of personal care to each of the residents and confirmed that a record of this information is kept in their personal support plan. Staff confirmed that personal support is always provided in private and by a person of the same gender where possible. This ensures residents privacy and dignity is maintained. A member of staff said, “I always make sure that windows, doors and blinds are shut when assisting a resident with personal care”. Another member of staff said, “it is very important to know and understand the persons routine and preferences with personal care”. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 15 Staff also confirmed that times for getting up and going to bed are flexible. The home has a ground floor walk-in shower and an assisted bath to promote residents safety. Residents’ physical and emotional health care needs are monitored and met with a record of any health care appointments being kept. Each person receives regular health checks from their GP, dentist, optician and chiropodist. Residents are also offered annual healthcare checks. Staff explained that where appropriate visits to the home by healthcare professionals are arranged for those residents that need or request them. The service operates a key worker system to enable residents to develop a closer relationship with a specific staff member particularly in the areas of health and personal care. The key worker is responsible for reviewing the resident’s monthly plan and to arrange healthcare appointments etc. for residents. During discussion a member of staff described clearly their role and responsibilities as a key worker. Staff are responsibility for the administration of residents medication to ensure their health and welfare. Staff have been provided with training in area and arrangements are being made for further training to be provided later in the year. Information provided in the AQAA showed that staff have access to policies and procedures relating to safe storage, handling and administration of medication. All residents’ medication and administration record sheets were looked at during the visit. All of the information recorded on these record sheets was hand written. Under such circumstances two staff signatures should be obtained following completion of these record sheets to ensure the accuracy of the information. This issue was discussed with the staff on duty that were advised to consult with the supplying pharmacist for the purpose of providing pre-printed medication administration record sheets. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 16 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. This judgement has been made using available evidence including a visit to this service. The homes policies and procedures ensure that residents are safe from harm, abuse and neglect. EVIDENCE: In the past year The Commission has not received any complaints about the home. The AQAA and records kept at the home showed that no complaints have been made directly to the home. Discussion with staff confirmed they were aware of the action they should take in the event of a complaint being made and a documented complaint procedure is available for staff, residents their family and friends. The staff spoken to during the visit confirmed they have received training around the protection of vulnerable adults from abuse and knew what action to take in the event of them suspecting an incident of abuse had occurred. They demonstrated different levels of understanding in this area. One member of staff said, “I would most definitely tell somebody the minute I thought a resident was being abused”. A copy of Seftons adult protection procedure was in place to ensure any allegations of abuse are dealt with correctly. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 17 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 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a comfortable and pleasant environment, which was free from hazards. EVIDENCE: The home is a large Victorian semi-detached house located in a popular residential area of Crosby, Merseyside. It is in keeping with the local community and provides a comfortable and homely environment for the people that live there. In addition to living space there is a large driveway at the front of the house with space for a minimum of two cars and a garage attached to the side of the house. There is a large back garden with patio areas. Residents are able to access all parts of the inside of the home, however they are unable to access the back garden directly from the inside of the house. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 18 This is because there are a number of steep steps leading out of the back door to the garden, which are unsafe for residents to use. The appropriate safety measures have been put in place to ensure the safety of the residents and they can access the back garden through a gate at the side of the house. A number of requirements were given as part of the last inspection report. This was because resident’s comfort and dignity was undermined by parts of the home, which were in poor condition. The AQAA showed that since the last inspection many improvements have been carried out to both the inside and outside of the home, which have improved the overall appearance and condition of the home to the benefit of the residents. All parts of the environment were looked at as part of the visit. This showed the following improvements since the last inspection: • • • • • • • • • Replacement PVC windows Outside sills and doors have been repainted The hall, stairs and landing have been repainted The ceiling in the kitchen has been re plastered and painted Kitchen worktops have been replaced Security lights have been fitted in the back garden The vestibule has been fitted with safety glass Broken fencing in the back garden has been replaced Redecoration of a residents bedroom A tour of the premises showed that the repairs have been carried out to a high standard. Each resident’s bedrooms were decorated and furnished to a high standard. They were warm, bright and well ventilated. All bedrooms were personalised to reflect the person’s own interests and hobbies. On the day of the inspection visit the home was very clean and tidy and there were no hazards identified. None of the residents smoke, however there are a number of staff that do. The none smoking policy at the home restricts staff and visitors from smoking inside the home, however a metal box for disposing cigarette stumps was mounted outside on the wall next to the front door, which is the designated smoking area. This is disrespectful to the residents because it is in full view of the neighbours, visitors and members of the public. The designated smoking area should be relocated out of respect for the residents that do not smoke and whose home it is. . Laundry facilities are sited in a utility room separate to the kitchen. The AQAA showed that the required policies and procedures for control of infection and cleaning routines are in place at the home. It also showed that soiled laundry is washed appropriately and clinical waste is disposed of in the correct way. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 19 The AQAA, discussion with staff and examination of records showed that staff have completed training in relation to infection control. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 20 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): 32, 34 & 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Recruitment and training procedures carried out at the home ensure that residents are supported by qualified and competent staff. EVIDENCE: The AQAA showed that strict staff recruitment procedures are in place, Expect is an equal opportunities employer and issues of equality and diversity are thouroughly addressed during the interview process. The staff spoken to during the visit confirmed they have completed a Criminal Records Bureau check to ensure they are fit to work with vulnerable adults. Staff records were not examined during this inspection because the manager was not on duty to provide access to them. However the AQAA showed that satisfactory recruitment checks have been carried out for all staff that work at the home. Examination of the staffing rota and the AQAA showed that there six staff work at the home and that the team is made up of people of various age, gender and ethnicity. The staff rota indicated there are a minimum of two staff on duty throughout the day and the night. The staff on duty at the time of the Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 21 inspection visit staff confirmed there were sufficient staff on duty to look after the resident properly. Discussion with staff and information provided in the AQAA and records seen at the home showed that staff have completed a range of appropriate training and a training programme for the forthcoming year is in place. This training covers a range of issues relating to the care and support of vulnerable adults and the efficient running of the home. For example first aid, health and safety, protection of vulnerable adults and fire awareness. The AQAA showed four staff that work at the home have an NVQ Level 2 or above in care and two staff are working towards it. The staff spoken to during the visit confirmed the organisation provided a lot of staff training which they were always encouraged to attend and enjoy. Staff receive induction training when first employed. All of this is in line with good practice and ensures staff are up-to-date with changing care practice issues and the law. Staff spoken to during the visit confirmed they receive regular supervision from the Registered Manager. They all confirmed this meeting was useful and gave them an opportunity to discuss their role, training and development. The staff spoke highly of the Registered Manager and confirmed she was committed to her job and always available for support and advice. The staff spoken to during the visit confirmed Expect was a good organisation to work for and they felt well supported in their role. Each member of staff spoke highly of other members of the staff team and confirmed they were all very flexible and hard-working. Comments made by staff included: “It’s a brilliant staff team” “Everybody works well together” “Everybody is hardworking” “Everybody treats the residents very well” Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 22 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, 39 & 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well run to the benefit of the residents. EVIDENCE: Since the last inspection Debra Thorpe has been approved by the Commission as the Registered Manager of the home. She is qualified and experienced to manage the service, which is run in the best interests of the residents and staff. She is qualified to National Vocational Qualification level 4, which is the recognised qualification for a manager of a residential care service. The AQAA showed that the Registered Manager has undertaken periodic training to update her knowledge and skills. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 23 Staff spoken to during the inspection spoke highly of the manager, comments they made included: “The manager is flexible” “The manager is very approachable and considerate” “She is easy to talk to and down to earth” “The manager is caring and very good at her job” Systems are in place to ensure the ongoing monitoring and improvement of the service provision. This includes supervising staff, reviewing administrative procedures and reviewing residents care packages to ensure their current care need requirements are being met at the home. A manager from another residential service within the company carries out regular audits of the homes systems and procedures. Expect is an equal opportunities employer discussion with staff and information provided in the AQAA showed that up to date polices relating to this are in place at the home and understood by staff. The AQAA also showed that all other policies, procedures and codes of good practice which are required for this type of service and which are listed in the National Minimum Standards and Regulations for Care Homes for Adults (18-65) are available at the home. There was evidence to show that all the documents have been reviewed and updated since the last inspection so that staff, residents and their representatives have accurate and up to date information ensuring their health safety and welfare. The AQAA also showed that equipment used at the home has been serviced or tested as recommended by the manufacturer or other regulatory body. The AQAA also showed that all the required checks have been regularly carried out on equipment used at the home. They include electrical circuits, portable electrical equipment, heating system and gas appliances. A selection of certificates and records, which were seen, supported this information. Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 24 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 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 X 26 X 27 X 28 X 29 X 30 4 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 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 X 3 3 X 3 X X 3 X Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 25 No 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. 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 Handwritten information recorded on Medication administration record (MAR) sheets should checked and signed for by two staff to ensure the accuracy of the information. A request should be made to the supplying pharmacist to provide pre-printed medication administration record sheets. The designated smoking area should be relocated out of respect for the residents that live at the home and do not smoke. 2. YA24 Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 26 Commission for Social Care Inspection Merseyside Area Office 2nd Floor, South Wing Burlington House Crosby Road North Waterloo L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Belvidere Park, 6 DS0000005248.V343528.R01.S.doc Version 5.2 Page 27 - 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. 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