CARE HOME ADULTS 18-65
Clare Walk, 3 3 Clare Walk Fazakerley Liverpool Merseyside L10 4YG Lead Inspector
Mrs Janet Marshall Unannounced Inspection 25th October 2005 09:30 Clare Walk, 3 DS0000021519.V262357.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 Clare Walk, 3 DS0000021519.V262357.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. Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 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.V262357.R01.S.doc Version 5.0 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 5th May 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 resident. Another resident 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 an 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. Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. Two inspection visits are required at the home each year, this was the second. There has been no cause for any visits to the home since the last routine inspection in May 2005. The inspection was unannounced and took place over six hours. The requirements and recommendations from the last inspection report were discussed and checked with the manager. A tour of the home was conducted. A selection of care records and other required records were inspected. Records that were examined included residents care plans, daily diaries, medical notes, medication sheets, staff rotas and records of health and safety checks. Both residents were at home during the visit, their views about the home were obtained along with those of a relative who was visiting the home on the day of the inspection. Both residents were ‘case tracked’. Case tracking means that the inspector concentrates on the care given and experiences of one or more residents to ensure that the persons needs are recorded in their care plan and are being met. What the service does well: What has improved since the last inspection?
The Homes statement of Purpose and Resident Guide has been developed so that prospective residents have better information about the home. Contracts have been signed which shows residents have agreed to the terms and conditions of the service. All staff working at the home have undertaken POVA training, which ensures the protection of residents.
Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 6 The required Health & Safety Policies and procedures are available at the home so that the health, safety and welfare of residents are promoted and protected. The manager has carried out and recorded comprehensive assessments of staff training needs. This ensures that staff undertake the required training. Records required for the protection of residents and the efficient running of the home are better maintained. The manager has commenced NVQ Level 4 in management and care and is progressing well with it. Bank statements for residents are kept in their individual files so that they have a record of their savings and all transactions made. What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. Clare Walk, 3 DS0000021519.V262357.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 Clare Walk, 3 DS0000021519.V262357.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): 1, 2 & 5 Information about the home is more detailed so prospective residents have the information they need to make an informed choice about living at the home. Assessments carried out prior to admission were available for both residents ensuring care needs will be met. Contracts were signed which shows residents have agreed to the terms and conditions of the service. EVIDENCE: The homes Statement of Purpose and Resident Guide were viewed. Since the last inspection they have been developed to include better information about the home. The information about the service is now more detailed so that prospective residents have the information they need to help them decide about living at the home. Assessments for both residents were viewed. Assessment information completed by the home now includes more information about each residents care and support needs. Assessments carried out by the Care Management Team are now available for both residents. A contract for both residents was available in their individual files. Since the last inspection the resident and/or their representative have signed them. Clare Walk, 3 DS0000021519.V262357.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 Care plans have been signed to show that residents and their representatives were involved in developing them. Residents are provided with the information, assistance and support that they need to make choices and decisions about their own lives. Risk assessments were not detailed enough putting residents at risk of harm. EVIDENCE: At the last inspection care plans were not signed by residents and/or their representatives to show that they are involved and agree with their plan of care. Care plans that were seen showed that they have now been agreed and signed. The parent of one resident said that both her and her daughter are fully involved in reviewing the care plan. Discussion with staff showed that they respect residents rights to make choices and decisions. Staff were seen offering choices to residents and supporting them to make appropriate decisions. The choices and decisions that residents are able to make for themselves and those made by others and the reason why is recorded in their care plans. One resident attends an advocacy group weekly. The resident particularly enjoys this activity, which is recognised and supported by the staff.
Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 10 Risk assessments that were seen at the last inspection did not include enough information about the action to be taken to minimise the level of risks and hazards, therefore potentially putting residents at risk. Some risk assessments have been developed to show how better to minimise risks. The manager said that she is in the process of developing others. Clare Walk, 3 DS0000021519.V262357.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): 11, 15 & 17 Residents are given opportunities for personal development. Relationships are encouraged so that residents maintain contact with family and friends. Residents are encouraged to eat food that is healthy and enjoyable. EVIDENCE: Each resident has a personal development plan, which shows that they are given opportunities to learn and develop life skills. A member of staff was seen supporting a resident to cook. This task was recorded in her plan as an area for development. The records showed that staff are consistent in supporting residents to develop the skills that have been identified. Records showed that residents have regular contact with family and friends. Discussion with staff showed that they encourage residents to develop and maintain relationships. The relative of one resident said that she visits the home regularly and is always made to feel welcome. A 4-week menu was seen at the home. The menu showed a choice of food that is well balanced and healthy. Residents said that they go shopping for
Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 12 food and help to prepare it. One resident was seen helping to prepare lunch and the evening meal. The resident said that she enjoys all her meals. Clare Walk, 3 DS0000021519.V262357.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 & 20 Medicines are administered according to the home’s policy and procedure. Staff were observed providing care and assistance to residents in a polite and sensitive manner. EVIDENCE: Discussion with residents confirmed that staff provide a good standard of privacy and are respectful of their individual wishes especially around personal care. Residents confirmed that staff knock on bedroom doors before entering and that they are respectful. The staff were observed to be polite, sensitive and caring with the residents. Care plans include a good amount of information about residents personal and healthcare needs. One resident confirmed that she chooses what to wear, what time to go to be and when to get up. Medication sheets were seen and these were completed to a satisfactory standard. One resident applies cream for a skin condition. Staff encourage this but assist with the areas that she finds difficult to reach. Medication training has been provided to all staff that administer medication. Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 14 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 & 23 The homes complaints procedure does not include all the relevant information to enable residents to make a complaint in the proper way. Protection of Vulnerable adults (POVA) training has been completed by all staff providing the necessary safeguards and protection for residents living in the home. EVIDENCE: The homes complaints procedure was examined it needs to be further developed to include information about the stages and timescales involved in the process. The procedure also needs to include more information about how to complain and who to complain to. The relative of one resident said that she would be confident about raising concerns should any arise. Residents confirmed that they have no concerns about the home. Since the last inspection all staff have completed protection of Vulnerable Adults (POVA) training. One member of staff said that she was confident about what to do if a resident alleged an incident of abuse. Residents have their own bank accounts, which they can access when they want. A record of residents money is well kept. Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 15 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 25, 27 & 29 Residents bedrooms are furnished and equipped to suit their needs and lifestyles. The décor in a residents bathroom is in poor condition compromising their comfort and dignity. The home has the equipment that residents need to help them be more independent. EVIDENCE: Residents bedrooms were seen. They are furnished and decorated to a satisfactory standard. A resident confirmed that she chose the colour scheme for her bedroom. Bedrooms are personalised photographs and other items chosen by residents are displayed around their rooms. One resident said that she is getting a new carpet and bedroom furniture, which she is choosing herself. The upstairs bathroom is equipped with a bath chair to help one resident get in and out of the bath more easily. Handrails and a walk in shower are also fitted at the home helping residents to be more independent. The en-suite bathroom on the ground floor needs decorating. Paint is peeling off the walls, which compromises the comfort and dignity of the resident.
Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 16 The home was clean and tidy. Staff were seen encouraging and supporting a resident to clean the house. Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 17 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 & 36 Staff have completed relevant training to ensure that residents needs are met. Staff are not always sufficient in numbers to meet the social needs of residents. The homes recruitment process ensures the protection of residents. Staff are not being formally supervised so that they are clear about their roles and responsibilities. EVIDENCE: Since the last inspection staff have undertaken training that is required of them. Recent training includes POVA, Health and Safety, First Aid, Manual Handling and Care of Medicines. Individual Training plans were seen. They show future training and development needs for each member of staff, which meet the needs of residents and the aims and objectives of the home. Staff training plans linked into a programme of forthcoming training for the home. The social needs of residents are not always consistently met. One resident is unable to get out as much as she would like to. This is because sometimes there is not enough staff on duty to support the different things they like to do. The manager said that she is in the process of recruiting another member of staff to support residents with social activities. Since the last inspection a new member of staff has started work at the home. Records kept at the home showed that they carry out the correct procedures
Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 18 before starting new staff. The procedures include CRB and POVA checks, which ensure the protection of residents. The manager said that she is not regularly supervising staff on a one to one basis. The manager and a member of staff said that discussions between them take place daily but are not recorded. The manager was advised that as well as daily contact all staff must have regular recorded supervision meetings with her. This ensures that staff are appropriately supported and fully aware of their roles and responsibilities. Clare Walk, 3 DS0000021519.V262357.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): 37 & 39 The manager is positive and open benefiting residents and staff. The provider is not providing the commission with reports to show that he is carrying out monthly visits to the home. The necessary checks are being carried out to ensure the health, safety and welfare of residents. EVIDENCE: The manager has commenced NVQ Level 4 in care and management and is progressing well with it. Staff and residents were complimentary of the manager describing her as open and positive. Although the provider visits the home, he is not interviewing residents and staff or inspecting the premises in a way that he must. It is important that he does this so that he can check records and form an opinion of the standard of care in the home. Following the visit the provider must write a report and send it to the Commission. Records showed that regular Health and Safety checks on the environment are being carried out and recorded.
Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 20 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 3 3 X X 3 Standard No 22 23 Score 2 3 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 3 X 2 X Standard No 24 25 26 27 28 29 30
STAFFING Score X 3 X 3 X 3 X LIFESTYLES Standard No Score 11 3 12 X 13 X 14 X 15 3 16 X 17 Standard No 31 32 33 34 35 36 Score X 3 2 3 X 2 CONDUCT AND MANAGEMENT OF THE HOME 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
Clare Walk, 3 Score 3 X 3 X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X X DS0000021519.V262357.R01.S.doc Version 5.0 Page 21 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. Standard Regulation Requirement Timescale for action 25/11/05 1. YA9 2. YA22 3. YA27 4. YA33 5. YA36 6. YA39 7. YA39 The manager must ensure that all risk assessments include 13(4)(a)(b(c) detailed information about the action required to reduce the level of risk. The manager must develop the complaints procedure and 22(1) make it more accessible to residents. The manager must arrange for 23(2)(b) the re-decoration of a residents bathroom. The manager must ensure that the home has sufficient 18(1)(a) numbers of staff to meet the needs of residents. The manager must ensure that all staff receive recorded 18(2) supervision at least six times a year. The provider must carry out monthly visits to the home 17(1) and provide the CSCI with written reports. The manager must obtain a business plan that ensures the 25(1)(2)(3) effectiveness, financial viability and accountability of the home. 25/11/05 15/12/05 15/12/05 30/12/05 25/10/05 25/10/05 Clare Walk, 3 DS0000021519.V262357.R01.S.doc Version 5.0 Page 22 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.V262357.R01.S.doc Version 5.0 Page 23 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
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