Inspection on 09/06/05 for Chelwood Avenue (7)

This inspection was carried out on 9th June 2005.

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

The inspector 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

Chelwood Avenue (7) 22/07/09

Chelwood Avenue (7) 24/07/08

Chelwood Avenue (7) 28/06/07

Chelwood Avenue (7) 16/11/06

Chelwood Avenue (7) 20/02/06

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 08/07/2008.

CARE HOME ADULTS 18-65 7 Chelwood Avenue 7 Chelwood Avenue Childwall Liverpool L16 3NN Lead Inspector Peter Cresswell Announced Thursday, 9 June 2005 9.00am th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service 7 Chelwood Avenue Address 7 Chelwood Avenue, Childwall, Liverpool, L16 3NN Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0151 722 2854 Chelwood@cic.sps.home Community Integrated Care Craig Kirkwood (application under consideration) PC Care Home Only 3 Category(ies) of Learning Disability registration, with number of places 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None Date of last inspection 9 June 2005 Brief Description of the Service: Chelwood Avenue is home to two adults with learning disabilities and is run by Community Integrated Care, a major local not-for profit organisation. Although the home is registered for three service users only two bedrooms are now available and there are no plans to admit a third service user. The home is a semi-detached house in a quiet suburb of Liverpool, close to a small parade of shops, bus routes and the M62. There is a large lounge, dining room and a small kitchen downstairs. Upstairs there are two spacious single bedrooms, bathroom and a small room which is currently used as a staff sleep-in room. There is a large garden to the rear of the house. One of the service users has a minibus that is used for both service users, with the other making a financial contribution to its running costs. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This inspection was announced. The inspector met both of the service users and the staff on duty as well as the manager. He observed staff working with the service users including them being taken out in the minibus. He toured the home and inspected records, including care plans, fire safety and medication records. 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. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Standards Statutory Requirements Identified During the Inspection 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2, 5 The owners’ assessment procedures would ensure that new service users were appropriately admitted to the home. EVIDENCE: The present service users have lived at Chelwood Avenue for many years now so no new admissions have been made. The company has an assessment procedure which would be used in the event of a new admission. The service users are tenants of Maritime Housing, which owns the property, and copies of the tenancy agreements were on file. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6, 7, 8, 9 Care planning is good and provides staff with the information they need in order to care for the service users. EVIDENCE: The care plans, risk assessments, Essential Life Plans and pen pictures on file contain a wealth of information on each service user and how care and support is to be provided. The plans are reviewed by the manager each month, with more formal reviews held annually. The service users have limited communication but they and their families are always consulted about proposed activities or other events that might affect their lives. Neither service user goes out independently but both are encouraged to go out with staff and family and take assessed risks appropriate to their capacity. A stair gate had recently been fitted to the top of the stairs following a fall. The gate allows staff to restrict access to the stairs when the service users are in their rooms. Fitting such a measure is an appropriate response to the risk but the risk assessment for it must be completed as soon as possible and a copy forwarded to the Commission for Social Care Inspection. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 9 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,12, 13, 14, 15, 17 The home supports and provides appropriate activities that meet the needs and likes of the service users. EVIDENCE: The service users take part in a wide range of activities and are encouraged to develop and retain everyday living skills. They use local community facilities such as local shops, supermarkets and parks with the support of staff. They enjoy individual activities but also go out together in the minibus. This belongs to one of the service users but arrangements have now been made for the other to make a contribution to its running costs, reflecting the fact that they both have use of the vehicle. Each service user takes separate holidays – accompanied of course by staff – and they enjoy the time alone, both in the house and at the holiday destination. One service user used to attend a day centre but this was suspended several months ago. Discussions have now resolved the issues that led to the decision by staff in the home and his family to stop attendance and he is due to start again soon. The manager said that when this happens the suggestion made at the previous inspection – to record activities at the day centre to avoid duplication – will be pursued. Activities are 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 10 recorded on file, though not always in enormous detail. The service users see their families as often as they and the family wish and one of them visits the family home regularly. Staff prepare meals which are nutritious and to the liking of the service users, and one of the service users helps with the shopping, which he greatly enjoys. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 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 standard(s) 18, 19, 20 Staff have a good understanding of the service users’ personal support needs and provide support accordingly. Medication procedures need some minor improvements in order to further ensure the protection of the service users. EVIDENCE: The personal support needed is set out on the files and is provided by staff in a sensitive manner. The service users receive all of the community and specialist health care that they need and this is recorded on the file. In one case medical appointments had not recently been recorded. There was no evidence that the service user had in any way suffered as a result, as the GP was visiting as required, but it is important that health care episodes are recorded on the file for future reference. Neither service user handles their own medication; medicines are safely stored and their administration is recorded using Medication Administration Record (MAR) sheets. Staff are trained in the administration of medicines. The pharmacist sometimes dispenses tablets in Monitored Dosage blister packs and at other times in bottles or boxes. This is likely to lead to confusion and the manager should insist that the dispensing pharmacist provides a uniform system. At the moment the home even keeps ‘spares’ of one medicine as the dispensing is sometimes delayed. This is plainly unsatisfactory – though outside the immediate control of the home - and needs to be addressed with the pharmacist. Two tablets were not in the blister pack but had not been signed 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 12 for on the MAR sheet by a member of staff. The manager felt that this took place when bank staff were on duty and will pursue the matter with them and remind them of their responsibilities. It would be useful if the home had a copy of the Royal Pharmaceutical Society’s Guide to the Administration and Control of Medicines in Care Homes. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 and 23 The home has satisfactory complaints and abuse procedures to protect the interests of the service users. EVIDENCE: The owners have comprehensive policies and procedures in relation to complaints and adult abuse and both are available in the home. No complaints have been received since the last inspection. All staff attended training provided by Liverpool City Council on adult abuse in April 2005. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24, 25, 26, 27, 28, 30 The home provides a comfortable and homely environment for the service users. EVIDENCE: Chelwood Avenue is a domestic semi detached house which blends in with the surrounding area and is furnished in an appropriate, homely style. Most floors now have a laminate surface which meets the needs of the service users whilst still looking homely and attractive. The large garden is accessible to the service users and is well used in warmer weather, though it could be maintained more attractively. Each service user has a spacious single bedroom and both rooms were well furnished and personalised to reflect the tastes of the individual. The large bathroom meets the needs of the service users and the bath has been resealed since the last inspection. However, the job has been done very poorly by the landlords and is already showing mould. It needs to be redone. The shared lounge and dining room are well decorated and comfortable. The third bedroom is no longer used as such and does not meet current space standards. It was changed to an office and then to a staff sleep-in bedroom following the fall referred to earlier. The use of sleep-in staff will be reviewed shortly. In any event the room is no longer available for a 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 15 service user and it would be appropriate for the Registered Person to apply for a variation to reflect the fact that the home can now only accommodate two service users. The home was clean and odour free. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 32, 33, 34, 35, 36 Staff recruitment and training procedures help to ensure that well trained staff are available to meet the needs of the service users. EVIDENCE: Sufficient staff are on duty to meet the individual needs of the service users. Three staff have NVQ2 and five are studying for the qualification so that the home will then meet the national standard for qualified staff. Staff receive appropriate training including a four day induction course and a three day ‘offthe–job foundation course’. Recruitment records for a new member of staff were satisfactory, though some details are kept at the owner’s headquarters. The manager interviews all staff who are being interviewed for a job at Chelwood Avenue and also helps with interviews for staff being interviewed either for general vacancies or in other establishments. Staffing is quite stable and there is not a high turnover of staff, helping to provide stability and continuity for the service users. Staff receive regular supervision, which is recorded. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37, 38, 40, 42 The home is effectively managed and safety procedures are observed, ensuring that there is a safe environment for the service users. EVIDENCE: The manager is studying for an NVQ4 and also hopes to take a course leading to an NVQ” Assessor’s qualification. His application for registration is currently with the Commission for Social Care Inspection. The manager has an open management style and there was a relaxed atmosphere in the home. Records are comprehensive and securely stored. Fire safety checks and training were up to date; valid gas and electrical safety certificates were in place. Those aspects of the service users’ finances dealt with by the home were accurately maintained and receipts were kept for any money spent from their personal allowance. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 18 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 x x 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 x 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 3 Standard No 31 32 33 34 35 36 Score x 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 7 Chelwood Avenue Score 3 3 2 x Standard No 37 38 39 40 41 42 43 Score 3 3 x x x 3 x F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 19 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. 1. Standard 20 Regulation 13(2) Requirement Timescale for action With immediate effect 2. 24 23 The Registered Person must make arrangements for the safe administration of medicines by ensuring that staff accurately record the administration of each individual dose. The Registered Person must 1 July 2005 ensure that the home is in a good state of repair by ensuring that the bath is adequately sealed. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. Refer to Standard 20 20 19 9 Good Practice Recommendations The home should obtain a copy of the Royal Pharmaceutical Societys guide to the administration of medicines in care homes. The manager should request that medicines are dispensed in a consistent format by the homes community pharmacist. Staff should record all medical appointments and interventions. The manager should forward to the CSCI a copy of the completed risk assessment about the stair gate. F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 20 7 Chelwood Avenue 5. 25 The Registered Person should apply for a variation to ensure that the homes registration is consistent with its capacity. 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 Page 21 Commission for Social Care Inspection Liverpool Office 3rd Floor, 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI 7 Chelwood Avenue F52 F02 S25236 7 Chelwood Avenue V226561 090605 Stage 4.doc Version 1.30 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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