CARE HOME ADULTS 18-65
Cherryvale Cherryvale Acrefield Road Liverpool Merseyside L25 5JN Lead Inspector
Lynn Sharples Unannounced Inspection 24th November 2005 09:30 Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 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.V268188.R01.S.doc Version 5.0 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.V268188.R01.S.doc Version 5.0 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) Community Integrated Care Ms Marion Joan Higgins Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: Date of last inspection 15th December 2004 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.V268188.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. There were three people living at Cherryvale at the time of the visit. The home did not know about the visit and took four hours. The inspector spent time with the service users and spoke to the two staff on duty. What the service does well: What has improved since the last inspection? What they could do better: Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 6 The home needs a registered manager in post. In accordance with their activity plans service users should be provided with more opportunities to be involved in the community including regular access to activities and social events outside of the home. 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.V268188.R01.S.doc Version 5.0 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.V268188.R01.S.doc Version 5.0 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): 2,5 The homes Statement of Purpose, Service User Guide and written contract provide service users and prospective service users with details of the services and facilities enabling an informed decision about admission to the home. EVIDENCE: Each service user has an Essential Lifestyle Plan which details the persons 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. Service users have been placed with CIC since moving from Olive Mount Hospital. Sample assessments were found to be in place. One service user moved from another home within the organisation and their assessment information was found to be on file. Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6,7,9 Service users needs are reflected in their care planning and they are supported in making decisions and taking risks as part of their lifestyle and routines. EVIDENCE: 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. 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. 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
Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 10 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 the service users are able to attend the house meetings if wished and the service users can accompany staff on shopping trips for both personal and household items. Evidence was provided to support this standard. Risk assessments are carried out for both personal and environmental risks and reviewed regularly. There was evidence on file that service users families’ views on change are sought where possible. Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15,16,17. Service users have weekly activity plans, which show that they are involved in community-based activities. However, one service user had not been out with the staff for a month. Visitors are welcomed at the home and people do call in at the home. Dietary needs of services users are well catered for with a balanced and varied selection of food available that meets service users tastes and choices. EVIDENCE: Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 12 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 activity plans did not reflect what the service users actual participated in. One service user had attended the day centre but not participated in any community-based activities for a month. Visitors are welcome at the home at any reasonable time and can either use the service users’ bedroom or the communal rooms such as the lounge. Evidence was provided through discussion with the staff that service users privacy is always maintained by staff who knock before entering rooms, provide keys for each service users bedroom and preserve dignity when assisting with washing and dressing. 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 provide a nutritional balanced diet; the staff consult with nurses to provide the appropriate diet for the service users needs. During the inspection Essential Lifestyle Plans, weekly activity plans and menus were inspected and staff on duty where interviewed. Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20. The service users receive the appropriate personal support in the way they prefer and require. The service users’ physical and emotional health needs are well met. The medication at this home is well managed promoting good health. 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 is aware of how to contact the relevant agencies such as G.P.’s dentists etc., and staff will accompany any service who needs to visit hospital for consultation. Talking with the staff it was clear that the dentist visits the home, however, this was not recorded on the Visits to the Dentist form in one service users file.
Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 14 None of the current service users self medicate. Policies are in place to support staff to assist any service users who wish to self medicate. The medication administration records were inspected and found to be accurately recorded, the stocks are kept securely in a locked cupboard and a random sample of the stock balances found that there was no record of how many paracetamols were in stock. Patient information leaflets for each drug supplied to each service user is now in place. The Medication Administration Records and care plans were inspected. Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 15 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): 23 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. It has recently been revised to include reference to the service user guide and CSCI. 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.V268188.R01.S.doc Version 5.0 Page 16 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): 24,25,27,29,30. The standard of the décor within the home is good with some evidence of improvement. The home is comfortable and homely environment for service users. EVIDENCE: Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 17 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 mal-odour. 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 is broken and needs repairing, this has been reported by the staff. The bed rail bumpers on one bed needs repairing, the staff has reported this. The inspector recommended that the staff team consult with an external agency to risk assess the use of the bed rails. 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. The garden area of the home is maintained by the housing association who own the premises and was generally neat and tidy T Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 18 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): 31,32,34,35. Staff require a registered manager to supervise them in the daily running of the home and provide leadership. Staff morale is high resulting in an enthusiastic workforce that works positively with service users to improve their whole quality of life. EVIDENCE: The registered manager left in October this year and there is currently no manger in place. The staff currently working at the home is 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 client group and have undertaken relevant training. 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. Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 19 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): The lack of a registered manager leaves the home without effective leadership and supervision. There is a clear care planning system in place to provide staff with the information they need to satisfactorily meet service users needs. EVIDENCE: The home carries out regular quality assurance audits and the Service Manager visits the home monthly and also carries out a thorough audit of service users’ health and welfare, accidents, risk assessments both personal and environmental, staffing levels and other issues. There is an annual survey sent out to relatives of service users asking for their views of the home from Head Office. The policies and procedures for the home are reviewed regularly and amended if necessary. There is a health and safety at work policy on display at the home and staff are given training in first aid. There is annual fire safety training and the home conduct regular fire drills. The home provides appropriate protective aprons and gloves and there is a contract with a local firm for disposal of any clinical waste. The accident book was inspected and no concerns were raised. Through constant monitoring and regular auditing the health and safety of both service users and staff who work at the home is
Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 20 protected as far as reasonably practical. Outside agencies such as the gas service, fire brigade and electricity board carry out regular safety checks and have issued safety certificates. The organisation has provided evidence of financial viability to CSCI Headquarters in Newcastle. An up to date liability insurance certificate was on display as well as the registration certificate. Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 21 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 Score X 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 3 X Standard No 24 25 26 27 28 29 30
STAFFING Score 3 3 3 3 3 3 3 LIFESTYLES Standard No Score 11 X 12 3 13 3 14 2 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 3 3 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Cherryvale Score 3 3 3 X Standard No 37 38 39 40 41 42 43 Score 2 2 3 3 3 3 X DS0000025237.V268188.R01.S.doc Version 5.0 Page 22 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 YA37 Regulation 8 Requirement Timescale for action 23/01/06 2 YA13 12 3 YA14 12 The registered person must ensure that a manager is in place that is appropriately qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. The registered person must 06/12/05 ensure staff support service users to become part of, and participate in, the local community in accordance with assessed needs and the individual Plans. The registered person must 06/12/05 ensure service users have adequate access to, and choose from a range of, appropriate leisure activities. 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 Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 23 1 YA29 Provision of bed rails and bumpers are assessed by, and meets the recommendations of, an occupational therapist or other suitably qualified specialist. Cherryvale DS0000025237.V268188.R01.S.doc Version 5.0 Page 24 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
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