Inspection on 24/07/08 for Chelwood Avenue (7)

This inspection was carried out on 24th July 2008.

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 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Chelwood Avenue (7) 22/07/09

Chelwood Avenue (7) 28/06/07

Chelwood Avenue (7) 16/11/06

Chelwood Avenue (7) 20/02/06

Chelwood Avenue (7) 09/06/05

Chelwood Avenue (7) 29/10/04

Chelwood Avenue (7) 22/04/04

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

Extracts from inspection reports are licensed from CQC, this page was updated on 27/09/2008.

CARE HOME ADULTS 18-65 Chelwood Avenue (7) 7 Chelwood Avenue Childwall Liverpool Merseyside L16 3NN Lead Inspector Joan Adam Key Unannounced Inspection 24th July 2008 16:30 Chelwood Avenue (7) DS0000025236.V362718.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 Chelwood Avenue (7) DS0000025236.V362718.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. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Chelwood Avenue (7) Address 7 Chelwood Avenue Childwall Liverpool Merseyside L16 3NN 0151 722 2854 0151 722 6502 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 Manager post vacant Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 28th June 2007 Brief Description of the Service: Chelwood Avenue is registered to care and offer support to two adults with a learning disability and is run by Community Integrated Care, a major local notfor profit organisation. 7 Chelwood Avenue is a semi-detached house in a quiet suburb of Liverpool, close to a small parade of shops, the M62 and bus routes to Liverpool city centre. Downstairs there is a large lounge, dining room and a kitchen. Upstairs there are two spacious single bedrooms, a bathroom and a small room that is currently used as a staff sleep-in room. The former garage has been converted to an office and utility room There is a large garden to the rear and side of the house. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The overall quality rating for this service is one star. This means that the people who use the service experience adequate quality outcomes. An unannounced visit took place on the 22 July 2008 and lasted 4.5 hours. Feedback was given to the acting manager on 24th July 2008 The visit was carried out by one inspector. This visit was just one part of the inspection. Before the visit the acting manager was asked to complete a questionnaire to provide up to date information about services in the home. Other information received by CSCI since the last key inspection was also reviewed. During the visit various records and the premises were looked at. Staff on duty were spoken with and the resident was spoken with. What the service does well: What has improved since the last inspection? Information was available to show that basic care plans and risk assessments are in place to make sure that the residents receive the support they need. The home has been completely redecorated so that the environment is a nice place to live. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 6 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. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 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 Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 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. 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. Residents’ needs would be fully assessed before they live at Chelwood so that the staff team know they can meet their needs. EVIDENCE: There have been no new admissions to the home since the last inspection. The company has a pre-admission procedure in place which states that no resident would be admitted without a full assessment and meetings with the multidisciplinary team, prospective resident and their family or advocate. The prospective resident would be invited to visit the home and stay for short periods prior to a decision being made to live there. It was not possible to assess this standard fully as the resident living at the home has been there for a number of years. Chelwood Avenue (7) DS0000025236.V362718.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): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The resident’s health, personal and social care needs are met by the staff team who enable privacy and dignity to be maintained. EVIDENCE: The care records for the resident living at the home were looked at. The file contained a care plan, risk assessments and health action plans. The care plans were clearly written and gave a clear picture of the support needed. However, the plans were not regularly reviewed as the needs of the resident had not changed. It was discussed with staff present that a review date should be set for care plans and risk assessments. Communication sheets were in place to enable staff to know how the resident communicates to make their needs known. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 10 A risk assessment was in place concerning interactions between the resident living at the home and another resident who has not lived at the home for some time. This needs to be filed away. A new up dated risk assessment was in place with regard to the safety gate at the top of the stairs so that the residents’ safety was maintained. Daily record sheets were detailed and covered all areas of daily living and were accurate, clearly written and signed by carers. Chelwood Avenue (7) DS0000025236.V362718.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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ were able to take part in a range of activities. Personal and family relationships were encouraged by the home and the staff team supported people with this. EVIDENCE: The resident attended day care Monday to Friday. Staff on duty were aware of what the resident liked to do at weekends and when they returned home from day care. A personal communication diary was in place to enable all staff to be aware of the residents likes and dislikes. The family visited on a regular basis and took the resident home or for trips out. The home has a car which is used to take the resident for outings to local shops and parks or just for a ride out. The care plan and staff spoken with stated that the resident would indicate if they did not wish to get out of the car. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 12 Meals are cooked by the staff and they are aware of the residents’ likes and dislikes. A risk assessment was in place for the risk of choking and the resident was observed throughout meal times by a staff member. Chelwood Avenue (7) DS0000025236.V362718.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 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The residents’ health, personal and social care needs are met by the staff team who enable them to maintain their privacy and dignity. EVIDENCE: The care plan gave a good picture of the routines of the home and the resident cared for. The resident tended to visit GP’s, chiropodists, opticians and dentists in the local community. These professionals would visit the home on request. Appointments with consultants and other hospital appointments were also undertaken. Records were kept of all these visits and they were up to date. Staff said that they supported residents on these visits. The home uses a Monitored Dosage System supplied by a local chemist. It is kept in a secure cupboard in the office. Medication Administration Record sheets were seen and appropriately completed. No Controlled drugs are kept at the home at this time but appropriate storage is available should this be needed. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 14 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. Clear policies and procedures were in place to ensure that residents were protected from abuse, neglect and self-harm. EVIDENCE: The home has a complaints procedure in place. The home or CSCI have not received any complaints since the last inspection. The homes policy on protecting adults from abuse included information about reducing the risk, types of abuse and what to do in the event of witnessing abuse. Staff received training with regard to safeguarding adults in 2006 and an up date course is to be arranged in the near future. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 15 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. The home provides a clean and comfortable environment for the people to live in. EVIDENCE: The home was clean and comfortable and was furnished in a domestic style. The home has been completely redecorated and all requirements regarding the environment had been met. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 16 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. Staff are trained, skilled and provided in sufficient numbers so the people who live at the home receive the care and support they need. EVIDENCE: The duty rotas showed that there were two staff on duty during the day, when the resident was not attending day care, and one care at night. Only one staff member has not as yet undertaken NVQ level two training but has a degree in social care. The acting manager has completed NVQ level three in care. Mandatory training has taken place for manual handling, fire safety, first aid, mental capacity awareness, and an autism training day. Recruitment files were not seen but only one staff member has been employed since the last inspection. When spoken with they confirmed that an enhanced CRB check had been carried out and two written references had been requested prior to them commencing employment at the home. They also stated they had undertaken a full induction course. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. A permanent management structure needs to be in place to ensure that the home is run well and to ensure that the changing needs of residents can be met in full. EVIDENCE: The home has been without a registered manager for some time. The last manager left the home but was not registered with CSCI. This is an out standing requirement from the last inspection. A staff member who is familiar with the home has been acting manager since January 2008. Staff meetings are held on a regular basis and minutes are taken. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 18 The AQAA states that safe working practices include fire safety in which all weekly checks are carried out and recorded, up to date certificates for gas safety, electrical safety and Portable Appliance Tests were available. Tests and servicing for all equipment for moving and handling had been completed. The fire book was seen and weekly fire system checks were completed, monthly emergency lighting tests. The accident book was seen and records were appropriate and filed in the service users file. The service user does not have verbal communication skills and so it was not possible during the inspection to ascertain their views of the home or whether they considered that their individual needs are being met. Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 19 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 3 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 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 X 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 x 2 X 2 X X 3 x Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 20 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 YA38 Regulation 8 Requirement The registered person must ensure that a registered manager is appointed and an application to register the appointed manager is made with CSCI. Unmet requirement from 30/10/07 Care plans must be kept under review to demonstrate that people’s changing care needs have been identified and effective measures taken to meet those changed needs. Timescale for action 30/09/08 2 YA6 2(b) 31/08/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 21 Commission for Social Care Inspection North West Regional Office 3rd Floor Unit 1 Tustin Court Port Way Preston PR2 2YQ 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 Chelwood Avenue (7) DS0000025236.V362718.R01.S.doc Version 5.2 Page 22 - 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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