Inspection on 16/06/06 for Clare Walk, 3

This inspection was carried out on 16th June 2006.

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

Other inspections for this house

Clare Walk, 3 31/07/07

Clare Walk, 3 25/10/05

Clare Walk, 3 05/05/05

Clare Walk, 3 12/10/04

Clare Walk, 3 04/05/04

Clare Walk, 3 02/02/04

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 Clare Walk, 3 3 Clare Walk Fazakerley Liverpool Merseyside L10 4YG Lead Inspector Mrs Janet Marshall Unannounced Inspection 16th June 2006 09:00 Clare Walk, 3 DS0000021519.V290751.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 Clare Walk, 3 DS0000021519.V290751.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. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Clare Walk, 3 Address 3 Clare Walk Fazakerley Liverpool Merseyside L10 4YG 0151-523-5402 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) Clare Care Mrs Valerie Lee Yong Care Home 3 Category(ies) of Learning disability (3) registration, with number of places Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 3 LD The service should employ a suitably qualified and experienced manager who is registered with the CSCI 25th October 2005 Date of last inspection Brief Description of the Service: 3 Clare Walk is an extended four bedroom town house located in a popular residential area of Fazakerley. The home is registered as a care home for up to three people with a learning disability. Currently there are two women in residence. The home is located close to local amenities and public transport. An extension on the ground floor of the property provides a bedroom and ensuite, which is occupied by one service user. Another service user occupies one of two registered bedrooms on the first floor of the home. The smallest bedroom on the first floor of the home is used as office. Shared rooms on the ground floor include a lounge and a kitchen/diner. There is a garden at the front of the house and a good-sized yard at the back. 3 Clare Walk is part of a company called Clare Care that is owned by Mr Liam Allmark. The registered manager of the home is Mrs Val Lee Yong. The home provides a service for 52 weeks a year. The homes fees start at £754.00 per week. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first inspection visit (site visit) at the home this inspection year. The inspection was unannounced and took place for a total of 6 hours. The Commission considers 22 standards for Care Homes for Adults (18-65) as Key Standards, which have to be inspected at least once in a 12-month period. All Key standards, which are identified within the main body of the report, were inspected during this inspection. During the site visit the requirements and recommendations from the last inspection report were discussed and checked with the manager. Most of them have been met. Those that have not been met have been raised again as part of this report. There were no statutory requirements or good practice recommendations identified during this inspection visit. A tour of the home was conducted. Care records and other required records were inspected. Records that were examined included a selection of residents care plans, daily diaries, medical notes, medication and records, staff rotas and certificates of health and safety checks. Two residents were “case tracked”. Case tracking means that the Inspector concentrates on the care given and experiences of one or more residents to get an idea of what is like to live at the home and how that person’s needs are being met. A pre - inspection questionnaire, which was sent out to the home was completed by the manager and returned prior to the inspection. The manager, one member of staff and two residents were interviewed during the site visit. Prior to the inspection visit Surveys from the Commission for Social Care and Inspection titled ‘Have your say about…’ were given out to both residents on the day of the visit, they were completed and returned. Information provided in the pre - inspection questionnaire, comments made during interviews, observations made and records examined during the visit have been used towards measuring standards for the purpose of this report. What the service does well: Residents quality of life has been enhanced following the many improvements made to the service in the past two years. Through appropriate planning and support the service enables residents to achieve independent lifestyles. The service ensures that residents receive appropriate personal and healthcare support and deal with these issues sensitively. During the last two years many improvements have been made to the environment making it homely, clean, safe and comfortable for the people who live there. Residents benefit from a manager and staff group who are committed to providing them with a high standard of care and support. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 6 The service now provides all staff with mandatory training which ensures the health,safety and wellfare of residents. Comments made by residents and staff about the service include: “I Like living here”. “I choose what i do”. “I choose what to wear each day”. “I like my bedroom. I chose the new furniture and colour for my room which has just been decorated”. “I go out and on lots of holidays”. “I know who to talk to if I am unhappy”. “I choose what to eat each day and help to cook my meals”. “The staff are very nice”. “The manager is very good”. “I like going to museums and shopping with staff”. “The home is run well”. What has improved since the last inspection? What they could do better: The manager must develop the complaints procedure and make it more accessible so that people know how to make a complaint. As part of the homes quality monitoring processes the provider must carry out monthly visits in accordance to Regulation 26 of the Care Homes Regulations. A business plan that ensures the effectiveness, financial viability and accountability of the home must be provided. The service needs to provide written policies and procedures to ensure that resident’s rights and best interests are fully safeguarded. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 7 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. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 8 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Procedures followed by the home ensure that prospective and existing residents needs are appropriately assessed so that the home can be sure of meeting their needs. EVIDENCE: Assessments carried out by the care management team were available in both care files. Records showed that care plans are regularly reviewed and updated. Procedures were available for assessing and admitting new residents to the home. A member of staff said, “I think residents needs are fully met at the home” Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 & 9 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Residents make choices and decisions and take responsible risks as part of an independent lifestyle. EVIDENCE: Residents care plans, daily records and risk assessments were examined. These records showed that residents make choices and decisions in accordance to their individual plans of care. Care plans have been reviewed and updated since the last inspection. They were signed and dated by the resident and their representative evidencing the involvement of them in the development and reviewing of the documents. A member of staff said, I know about residents care plans, where they are stored and why they are important”. Residents are given a choice about where to keep their care plans. They can either keep them in a lockable cabinet in their rooms or locked up in the office. A signed statement agreeing to each person preferred arrangement regarding the location of their care plans was available in their care files. One resident said, “I keep my files in my own room”. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 11 Care plans contained a good level of information enabling staff to meet each persons needs. Care plans covered areas such as health and personal care, likes and dislikes, daily routines and ability, achievements, goals and personal development plans, risk assessments, activity programme and information about choice and decision making. Case tracking showed that residents are supported in accordance to their individual plans of care. Throughout the visit residents were observed making choices and decisions. The member of staff on duty respected resident’s rights to make decisions and choices she was seen advising and supporting residents in a sensitive and flexible way. A member of staff said, “it is important to offer residents with choices so that they can make decisions”. A member of staff was seen communicating with a resident using a book containing large colourful pictures and symbols. They demonstrated how it is used. It was very effective and clearly aided the resident with communicating choices and decisions. The member of staff said that Makaton sign language is also used when communicating choices and decisions with residents. Results of surveys and discussion with residents evidenced that they are encouraged and supported to make and choices about all aspects of their daily lives. Choices that have been made by others and why were recorded in residents care plans. For example use of keys and management of finances. Both residents have bank accounts which are in their own name and address, bank books and financial records were viewed at the home they were well and maintained and in good order. One resident said, “I always have my own money”. Risk assessments were in place for both residents. A requirement was given as part of the last inspection report for them to be developed to include information about the action staff need to take to minimise identified risks and hazards. Examination of risk assessments for both residents showed that this has been done. They also included a good amount of information on which to base decisions and were consistent with individuals plan of care. There was evidence that they have been reviewed and updated at regular intervals. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 15, 16 & 17 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Residents are encouraged to live an independent and healthy lifestyle. EVIDENCE: One resident attends day care two days a week, whilst the other resident is supported to take part in activities and daily routines in accordance to her plan of care. Records showed that both residents have a structured timetable of activities in the week. Case tracking showed that the programmes are consistent with each persons assessed needs wishes and preferences. During discussion both residents spoke about and confirmed their weekly timetables. Residents are involved in the following both at home and in the local community, art and craft, cooking, independent living skills and leisure activities. During discussion residents said that they were happy with activities at home and in the community. On the day of the site visit both residents were at home. They were observed taking part in a variety of activities and household routines for example, Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 13 laundry, general cleaning of the home preparation of meals and hobbies such as drawing and jigsaws. Care plans and daily records that were viewed included a good level of information and showed that residents are appropriately encouraged and supported to participate in activities both at home and in the local community. During discussion residents confirmed that they make use of services and facilities in the local community, for example, shops, cinema, pubs, museums and libraries. A social care support worker is employed at the home for a part of the week. The workers key role is to support residents to access the community on a one to one basis. An activity file was seen for both residents, which included records of planned and actual activities. A resident said, “I go out a lot”. Discussion with residents and examination of records showed that staff support them to maintain family links and relationships both at home and in the community. Residents confirmed that they receive visitors at home as well as keeping in contact with them either by telephone or by letter. A member of staff said, “residents family and friends are made welcome and can visit anytime”. A visitor’s book was available at the home. Both residents were seen being encouraged and supported to take part in daily routines at the home. They were seen preparing their own lunch, making drinks, laundering clothes, vacuuming and light cleaning. A member of staff was seen supporting residents with these tasks in a patient and sensitive way. Resident’s bedrooms were fitted with locks and they had a lockable cabinet. Information about the use of keys was recorded in individual’s plans of care. Residents were seen chatting to staff and to each other. Staff were seen interacting positively with residents throughout the visit. The home has a communal lounge and kitchen/dinning room, which were occupied by residents at intervals throughout the visit. Residents have access to all parts of the home other than each other’s bedrooms unless invited. For safety reasons both residents need to be accompanied by staff in the kitchen and bathrooms. This information is recorded in the individual’s plans of care. The manager said that regular meeting involving residents take place. This was confirmed during discussion with residents and staff. Records of the meetings and informal discussions were viewed. During the visit residents were seen choosing their lunch and preparing it with the support of a member of staff. The dining room, which is located at the far end of the kitchen, was bright and cheery. The kitchen was equipped with domestic style crockery and appliances, which are accessible to the residents. The manager said that plans have been discussed about the refurbishment of the kitchen/dinning area. Lunchtime was relaxed and unrushed one resident sat in the lounge and ate her lunch the other resident sat at the dining table. During discussion both residents said that they always have enough to eat and have a choice of food. They confirmed that they have drinks and snacks outside of usual meal times. The home operates a 4-week menu, which was clearly displayed on the wall in the kitchen. Menus included a good selection of Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 14 food that is healthy and varied in content. Food stores that were examined were well stocked with fresh frozen and dried goods. A resident said, “I go shopping and with staff and choose food that I like”. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 15 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 quality outcome in this area is good. This judgement has been made using available evidence including a site visit. The health and personal care needs of residents are met and safeguarded by procedures carried out by the home. EVIDENCE: Care plans for both residents were examined. They recorded individuals preferred routines, likes or dislikes with regard to personal care. Details of how staff must provide residents with support and personal care were available in good detail. This information showed that it has been recently reviewed and updated. During discussion both residents said that they choose when to get up and go to bed and what clothes to wear each day. Both residents were clean in appearance and well dressed. Detailed records showed that both residents are supported to access primary health care services which are located in the local community, for example chiropodist, dentist, GP and opticians. Records evidenced that residents are offered minimum annual health checks and that their health care needs are well met, monitored and supported. Details of appointments and outcomes were well recorded as well as changes identified in individuals health and personal care needs. During interview a member of staff showed good knowledge and understanding of each persons health and personal care needs, she also demonstrated a good Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 16 awareness of the main principles of care, including privacy, dignity and respect. The member of staff said, “It is iimportant to maintain the privacy and dignity of residents by knocking on doors before entering rooms, shutting doors, blinds and curtains when assisting with personal care, talking to residents politely and offering choices”. Medication and Medication Administration Record sheets were examined they were all in good order and appropriately stored. Records showed that medication is administered by staff that have undertaken the required training. A policy for the receipt, recording, storage, handling administration and disposal of medication was available at the home. A record of medication received and leaving the home was seen. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 17 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): 22 & 23 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Residents do not have the information that they need to make a complaint. EVIDENCE: There has been no complaints received by the Commission for Social Care and Inspection about the home since the last inspection. There were no recorded complaints at the home. A complaints procedure was viewed at the home. It included little information about the stages and timescales involved in the process. The manager was advised of this and the need to develop the procedure so that it includes a greater level of information so that residents and other people are clear about how to make a complaint and the processes involved. The homes complaints procedure was not available in a format that can be easily accessed by the residents. This was discussed with the manager. results of surveys and discussion with residents showed that they are confident about telling somebody if they were uphappy. A copy of Knowsleys local Authorities Protection of Vulnerable Adults procedure was avaialbe at the home. The manager confirmed that all staff have undertaken Protection of Vulnerable Adults training. Certificates of attendance confirmed this. During discussion staff showed a good awareness of what to do if they suspected abuse was taking place or if an allegation of abuse was reported to them. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 18 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 & 30 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. The home provides a comfortable and safe environment for the residents living there. EVIDENCE: A tour of the inside and outside of the house took place. The home is of domestic style and in keeping with others in the Road. The home has several shared spaces, which include a lounge, a kitchen/dining room. Residents were seen using these rooms during the visit. The home has a shared bathroom on the first floor and a combined toilet and shower room on the ground floor. Residents have their own bedroom, they provided a tour of their rooms. There is a staff sleep-in room and a small office on the first floor. All parts of the house were accessible to all residents. Neither of the residents are wheelchair users. There were no hazards identified at the time of the visit. Following a requirement given as part of the last inspection report the en-suite bathroom has been fitted with a new door, redecorated and provided with new fixtures and fittings. The resident who occupies the room said, “I am very happy with my bathroom”. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 19 The following improvements have also been made to the home since the last inspection: Vertical blinds have been fitted to all windows in the home. A new fire and television set have been installed in the lounge. New carpets have been fitted to residents bedrooms, the hall stairs, landing and the office. One residents bedroom has been redecorated and fitted with new bedroom furniture, a carpet and a new bed. The office has been painted. The electrical system throughout the house has been upgraded this included the relocation of sockets in the kitchen and lounge making them more accessible to residents. Both residents confirmed that they were involved in choosing furniture, fittings, carpets and colour schemes. Policies and procedures relating the health and safety of the environment were available in the homes health and safety manual, which was in the office and easily accessed by staff and residents. The locks on all bathrooms and toilets that were checked were found to be working. The outside of the home was checked. There is a garden to the front of the house and paved area displaying pot plants at the back, both were well maintained. Residents said that they purchased and made up the plant pots. The exterior decoration was in satisfactory condition. Resident’s bedrooms were viewed, they were clean and tidy. Bedrooms were decorated and furnished to suit the needs and wishes of each resident. All other furnishings, fittings and equipment in the home were of good quality, and were domestic, unobtrusive and ordinary. The pre-inspection questionaire and a selection of records seen at the home showed that the required testing of systems and equipment has taken place as the required intervals. All parts of the home were clean and tidy. Policies for the control of infection were available at the home. A domestic style washing machine and dryer was situated in the kitchen. During interview staff demonstrated an awareness of high standards of hygiene and control of infection. Both residents said that they are happy with all parts of the home, comments made by them to support this included: “I like my room, I chose the colours and Furniture”. “I am very happy with my bathroom now that it has been decorated”. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 & 35 The quality outcome in this area is good. This judgement has been made using available evidence including a site visit. Residents are supported and protected by staff that are appropriately recruited and trained. EVIDENCE: Recruitment, selection and equal oppertuities policies and procedures were available at the home. Following a requirement given as part of the last report the manager has recruited two new members of staff including a social support worker whose main role is to support residents to access social activities. Two staff files were examined in detail, including one for a newly recruited member of staff. Both files included all the information that is required before staff are able to commence work at the home. For example, two references, a police check and a fully completed application form. The files also included records of supervisions, individual training and development plans and copies of certificates. The manager said that all new staff undertake induction training in the first part of their employment, records of these could not be located on the day of the site vist. The member of staff who was on duty confirmed that she completed an induction programme in the first few weeks of her starting work at the home. The pre-inspection questionnaire and examination of records showed that all staff working at the home have received satisfactory police checks Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 21 The pre-inspection questionaire and staff records evidenced that people who work at the home have undertaken mandatory traning over the last year, including protection of vulnerable adults, first aid, manual handling, health and safety, administration of medicines and understanding learning disabilities. Future training includes all of the above for new staff and national vocational qualifications in care level 2 & 3. During interview a member of staff said that she is happy with the level of training. The pre-inspection questionaire shows that almost 50 per cent of the staff team have completed a national vocational qualification in care level 2 or above. Individual training and development plans that were available for each member of staff detailed both completed and future training. Records showed that training is linked to the aims of the home and residents needs. Records seen evidenced that regular recorded one to one supervision meetings between the manager and staff have been introduced following a requirement that was given as part of the last inspection report. This ensures that staff receive the support that they need to carry out their jobs. Comments made by residents about staff included: “All the staff are very nice”, “They help me when I ask” “Staff are very good” Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 22 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 41 & 43 The quality outcome in this area is adequate. This judgement has been made using available evidence including a site visit. Residents benefit from a registered manager who ensures the effective day-today running of the home, however this is undermined by the Registered Provider who is not fully carrying out procedures which are required to ensure that residents views about the home are taken account of. EVIDENCE: The manager confirmed that she has completed The Registered Managers Award. Staff and residents were complimentary of the manager describing her as open and positive. One member of staff said, “the home is run well, the manager is understanding, approachable, patient and focused on the residents needs”. As part of the services quality monitoring process questionaires are given out at regular intervals to residents and relatives to seek their views about the home. A number of completed questionaires were viewed during the visit. Residents said that they are asked their views about the home. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 23 The manager said that the registered provider, Mr Allmark, visits the home reguarly when he meets with both residents and staff, however he is not producing a report following visits in accordance to Regulation 26 of The Care Homes Regulations. Under the Regulation the registered provider must visit the home at least once a month to interview residents and staff to form an opinion of the standard of care provided in the home and inspect the premises, its record of events and records of any complaints. Following the visit they must prepare a written report on the conduct of the home, a copy of which must be kept at the home and sent to the Commission. This was a requirement given as part of the last inspection report. A business plan for the home was not available for inspection. This was a requirement as part of the last inspection report. The pre-inspection questionaire and examination of documents showed that the home does not have all the required policies and procedures that are required by regulation. A number of policies and procedures that were available need to be developed. Details of these were discussed with the manager. The pre-inspection questionaire and a selection of records examined at the home showed that health and safety checks on the environment are being carried out and recorded at the required intervals. Discussion with the manager and staff, the pre-inspection questionaire, a selection of records examined at the home showed that staff have undertaken health and safety training. Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 24 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 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 X 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X 2 X 3 Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 25 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. 6. Standard YA39 Regulation 17(1) Requirement Timescale for action 16/07/06 10. YA22 12. YA40 13. YA39 The provider must carry out monthly visits to the home and provide the CSCI with written reports. This is a previous inspection requirement. 22(1) The complaints procedure must be developed and made more accessible to service users. This is a previous inspection requirement. 12(1)(a) Detailed written policies and procedures covering the topics set out in Appendix 3 of the Care Home Regulations must be provided. This is a previous inspection requirement. 25(1)(2)(3) A business plan that ensures the effectiveness, financial viability and accountability of the home must be provided. This is a previous inspection requirement. 16/09/06 16/10/06 16/09/06 Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 26 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 Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG 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 Clare Walk, 3 DS0000021519.V290751.R01.S.doc Version 5.2 Page 28 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!