Inspection on 24/02/06 for Cherryvale

This inspection was carried out on 24th 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 no outstanding requirements from the previous inspection report, but made 13 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Cherryvale 19/12/08

Cherryvale 25/07/07

Cherryvale 16/11/06

Cherryvale 24/11/05

Cherryvale 15/12/04

Cherryvale 01/06/04

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 Cherryvale Cherryvale Acrefield Road Liverpool Merseyside L25 5JN Lead Inspector Lynn Sharples Unannounced Inspection 24th February 2006 10:30 Cherryvale DS0000025237.V282246.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 Cherryvale DS0000025237.V282246.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. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Cherryvale Address Cherryvale Acrefield Road Liverpool Merseyside L25 5JN 0151 428 4458 9999 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 Ms Marion Joan Higgins Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 24th November 2005 Brief Description of the Service: The home is set in a residential area of Woolton and is accessible by a fairly regular bus service during daytime hours and a less frequent bus service by night. The nearest train station is a bus ride away and not within walking distance. There are a variety of small shops and large supermarkets within Woolton Village as well as banks, post office cafes, bars and restaurants. All of the rooms used by service users are on the ground floor; there is a first floor to the dormer bungalow property, which is used for office and laundry facilities only. There is a private enclosed garden to the rear and side of the house, which is well maintained and there is a patio/paved area leading off from the lounge. The service users have the benefit of a mini bus with designated drivers for trips out locally or into Cheshire and Wales. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The home did not know about the visit and took three hours, the inspector spoke with the service users, staff on duty and the manager. The inspector read files and looked round the home. What the service does well: What has improved since the last inspection? What they could do better: The home should ensure that the manager is registered with CSCI. The Statement of Purpose should be up to date with all the relevant details included. The care plans and risk assessments should be reviewed on a regular basis. The service users should have access to an optician. The staff should be trained to cut service users toenails or the home should make alternative arrangements. The stock count for the medication should be correct and unused medication returned to the pharmacist. The non-slip flooring should be Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 6 assessed, the soft and light room redecorated and the radiator covers assessed. An appropriate professional should assess the bed rails. The windowsill in the bathroom needs repainting and a blind used in the bathroom. The staff should hold and record regular team meetings and be supervised on a regular basis. The registered person must ensure that they visit the home regularly and forward a copy of the report to CSCI. Staff should attend regular fire drills and the emergency lighting should be tested regularly. 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. Cherryvale DS0000025237.V282246.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 Cherryvale DS0000025237.V282246.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): 1,2,5 The homes Statement of Purpose is out of date and does not provide sufficient information for prospective service users to be clear about the services the home provides to meet their needs. EVIDENCE: The homes Statement of Purpose is out of date, it still has the last registered managers details on file and does not have a copy of the last inspection report. The service user guide is complete. Service users have been placed with CIC since moving from Olive Mount. Sample assessments were found to be in place. One service user moved from another home within the organisation, the assessment information was on file. Each service user has an Essential Lifestyle Plan (ELP) which details the person’s wishes and the care plans demonstrate that each persons needs are assessed The service users have a tenancy agreement with Maritime Housing and a contract/statement of terms and conditions with Community Integrated Care, which is located in service users files. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 9 Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9,10 The out of date care plans means that service users needs, aspirations and goals cannot be assessed. Service users are supported in making decisions as part of their lifestyle. The lack of review of risk assessments leaves the service users at risk of harm. EVIDENCE: The service users have a care plan and an Essential Lifestyle Plan (ELP); some care plans have not been reviewed for a year. The information contained in the plans was informative and easy to read and follow. The ELPs gave a good social background on each service user and detailed their likes and dislikes as well as how they wished to be assisted in the activities of daily living. The daily evaluation sheets reflected the care and activities of each service user and the personal and risk assessments were up to date. Service users are encouraged to make decisions for themselves. Evidence was provided in each file to support this. Choices include activities of daily living as well as pursuing hobbies such as visiting the light sensory room and eating out. The service users are also enabled to make choices regarding clothing and personal care. The service users are involved in the day-to-day running of the home on a limited basis due to physical and communication difficulties. All of Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 11 the service users are able to attend the house meetings if they wished and the service users can accompany staff on shopping trips for both personal and household items. Risk assessments are carried out for both personal and environmental risks. Some of the risk assessments have not been reviewed for over a year. Confidentiality is maintained at the home by all staff that are giving training during their induction period on the importance of maintaining confidentiality and good record keeping. All documentation relating to the service users is kept securely in the home and the premises is alarmed. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17 Links with the community are good and support and enrich service users’ social opportunities. The daily routines ensure that some preferences of service users are provided for. Dietary needs of service users are well catered for with a balanced and varied selection of food available. EVIDENCE: Staff encourage service users to use local facilities and services such as transport, restaurants, pubs, cafes and the library. None of the service users are in any full or part time education, however one service user attends a day centre three days a week and enjoys a variety of activities such as personal development and life skills. The home has its own transport and evidence demonstrated that the service users go out in the evening and at weekends. This was limited due to staffing and having a driver on duty. The service users pursue their interests as written in their ELP, however, one service user likes to go swimming and had not been for several months, the manager said that they will address this. The staff team are currently planning service users holidays for this year with the service users. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 13 Service users maintain contact with family and one service users visits their family on a monthly basis. Another service user is visited regularly by a family member; the staff explained that if they wished they go visit the service user in private. The staff were observed talking with service users and spending time with them. Two service users went out shopping whilst the inspector was there. The Essential Life Plans for each service user also details what each individual likes to do and is able to do, they give details of how privacy is to be respected and of daily routines. The menus were examined and were healthy, varied and nutritious. The staff are to be commended as they provide a high fibre diet, which has meant that the service users are now not visited by the district nurses. The inspector did discuss offering a choice of two meals to assist with choice making and to record the decision. The manager said they would look into this. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Personal support is offered in such a way as to promote and protect service users’ privacy and independence. The health needs of the service users are generally met. The systems for the recording of the stock medication could be improved. EVIDENCE: Personal support and health care needs are met in a positive sensitive manner at the home. Evidence provided in the care files supports this. All physical needs are documented and personal care is given appropriately. The recording charts above the service users beds did not assist with the service users dignity and the inspector recommended that they be stored elsewhere. Service users are encouraged to develop their own individual style of dressing and hairstyles, and advice is sought from their families where possible. Evidence was provided in the records to indicate that all healthcare needs of service users are continually being assessed and evaluated and when necessary action is taken to address any health matters that arise. All staff are aware of how to contact the relevant agencies such as G.P.’s dentists etc., and staff will accompany any service that needs to visit hospital for consultation. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 15 There was no record of service users accessing an optician the manager said that they would address this immediately. The inspector was informed that the staff cut service users toenails and are not trained to do so. The inspector said that either the staff are trained or alternative arrangements are made. The medication at the home was examined the stock count of paracetamols did not tally with the actual paracetamols in the cabinet. There was a large amount of medication that this not used, the inspector recommended that this is returned to the pharmacist. The manager said they would address these issues. The medication administration records were correct. All the staff have recently received training in medication. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): Staff have a good knowledge and understanding of Adult Protection issues, which protects service users from abuse. EVIDENCE: The home has a robust policy and procedure relating to complaints. All staff are aware of the home’s Adult Protection Policy and the Whistle Blowing Procedure. There have been no incidences reported since the last inspection. Staff is given training on induction on issues surrounding adult protection. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24,25,27,30 The overall quality of the furnishings and fittings is good, but some issues need addressing to ensure that the service users and visitors are not at risk of injury or harm. EVIDENCE: Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 18 The premises are leased from Maritime Housing who is responsible for maintaining the fabric of the building, and the parent company is responsible for internal decoration and provision of furniture. The home appeared warm and comfortably furnished, the standard of housekeeping was high and there was no evidence of malodour. The flooring in the hallway is apparently non slip, however, this was tested with a small amount of water and was very slippery, this could place service users and staff at risk. The manager agreed with this and said they would speak to their line manager. There is quite a lot of space in the home, as well as a large lounge and dining room, there is a soft and light room which houses a large padded pool, sensory lights, mirrors (non-glass), and a music centre. However the room was in need of refurbishment and further development if it is to be used fully as a sensory room. The fire in the lounge has been passed as safe, but old and aged and the home may require a new fire. The manager said that his is being addressed in a month or so. The radiator covers in the lounge appeared to block some of the heat from the radiators; they were not fixed securely to the wall and were a risk. The manager said they would look into buying new more efficient radiator covers. The inspector recommended that the staff team consult with an external agency to risk assess the use of the bed rails. The manager said they would contact the occupational therapist next week. The service users bedrooms were personalised with pictures, posters music centres and ornaments. The combined bathroom has been refurbished; it requires a blind/curtain to maintain the privacy of the service users and the paint on the windowsill is coming off. The garden area of the home is maintained by the housing association that owns the premises and was generally neat and tidy. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 19 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): 32,33,34,35,36 The home has an enthusiastic workforce that works positively with service users to improve their quality of life. The lack of staff meetings, supervisions and training leaves the staff without clear support and direction. EVIDENCE: The current manager has been in post a month and is applying to register as the manager. The staff currently working at the home are aware of their responsibilities and have access to their job descriptions as well as the GSCC guidelines. All of the current staff have had many years experience of working with the service users. The staff on duty on the day of inspection appeared to have a very good rapport with the service users and offered assistance in a friendly and patient manner. The home uses agency staff and this can be for 80 hours a month, last month this was 50 hours. The new manager has had one staff meeting, but the one before that was in July last year. The manager said that they would hold monthly staff meetings. The sample of staff records indicated that the correct checks had been completed before a new staff commenced work. The files contained statements of terms and conditions. There was also evidence of a probationary period. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 20 The staff team did not have a training needs assessment and had not received five days paid training last year. The manager said that this would be addressed. The new manager had started supervisions but agreed that before they had started this had not been carried out regularly. The home has a grievance and disciplinary procedures. The staff do not use physical intervention strategies at the home. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 21 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): 37,39,42 The home does not regularly review aspects of its performance and does not seek the views of service users, relatives. EVIDENCE: The new manager has been a registered manager before and is hoping to start their NVQ level 4 in a month; they have recently completed the forms to register as a manager. There was evidence that some self monitoring has taken place. A manager from the organisation visits the home monthly and records their findings, there were some months missing. This person should forward a copy of these findings to the CSCI office. The home would benefit from seeking the views of family, friends and advocates and record their findings. The emergency lighting had not been regularly tested, there had been two fire drills and not all staff had attended, the night staff require at least 3 fire drill Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 22 per year. There was evidence of the maintenance of electrical systems and equipment. Accidents and injuries to service users are recorded appropriately. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 23 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 2 2 3 3 X 4 X 5 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 X 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 2 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 2 34 3 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 2 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 2 2 X 2 X 2 X X 2 X Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 24 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 YA1 Regulation 4 Requirement The registered person must ensure that the Statement of Purpose is up to date with all the relevant details included. The registered person must ensure that the care plans are reviewed on a regular basis. The registered person must ensure that risk assessments regarding service users are reviewed regularly. The registered person must ensure that the service users have access to an optician. The registered person must ensure that the staff are trained to cut service users toenails or make alternative arrangements. The registered person must ensure that the stock count for the medication is correct and unused medication is returned to the pharmacist. The registered person must ensure that the non slip flooring is assessed, the soft and light room is redecorated and that the radiator covers are assessed. The registered person must DS0000025237.V282246.R01.S.doc Timescale for action 31/03/06 2 3 YA6 YA9 14 13 31/03/06 31/03/06 4 5 YA19 YA19 13 13 31/03/06 31/03/06 6 YA20 13 31/03/06 7 YA24 23 28/04/06 8 Cherryvale YA24 23 31/03/06 Page 25 Version 5.1 9 YA27 23 10 YA36 18 11 12 YA37 YA39 8 26 13 YA42 23 ensure that the bed rails are assessed by an appropriate professional. The registered person must ensure that the windowsill in the bathroom is repainted and that a blind is used in the bathroom. The registered person must ensure that the staff are supervised at least six times a year. The registered person must ensure that the manager is registered. The registered person must ensure that they visit the home regularly and forward a copy of the report to CSCI. The registered person must ensure that staff receive regular fire drills and that the emergency lighting is tested regularly. 31/03/06 28/04/06 28/04/06 31/03/06 31/03/06 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 Refer to Standard YA14 YA33 YA35 Good Practice Recommendations It is recommended that service users pursue their chosen interests. It is recommended that the staff attend regular staff meetings. It is recommended that staff receive five days paid training per year. Cherryvale DS0000025237.V282246.R01.S.doc Version 5.1 Page 26 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 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. 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