CARE HOME ADULTS 18-65
3 Clare Walk 3 Clare Walk Fazakerley Liverpool L10 4YG Lead Inspector
Janet Mordaunt Unannounced 5 May 2005 09:30am
th The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service 3 Clare Walk Address 3 Clare Walk Fazakerley Liverpool Merseyside L10 4YG 0151 523 5402 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Clare Care Mrs Valerie Lee Yong Care Home 3 Category(ies) of Learning disability - 3 registration, with number of places 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: 1) Service users to include up to 3 Learning Disability. 2) The Service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Inspection. Date of last inspection 12/10/04 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. Curretly there are two women in residence. The home is located close to local amenities and public transport. An extention 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. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced inspection that took place over 6 hours. Good progress has been made by the home in addressing the requirements given at the last inspection; the action taken by the home to meet them was discussed and checked. Throughout the visit discussion took place with one service user. The other service user who lives at the home was out for the day. Discussion also took place with one member of staff and the registered manager of the home. Information that is kept at the home about service users and the running of the home was looked at. Staff were observed interacting with the service user. A full tour of the home also took place. Service user comment cards were left at the home for service users to complete and return to CSCI if they wish, brochures About the Commission for Social Care and Inspection (CSCI) were also left at the home for service users and staff. What the service does well: What has improved since the last inspection?
Good progress has been made by the home in addressing the requirements given at the last inspection. Care Plans for both service users have been improved since the last inspection. They are more organised and better presented in individual files. They now include a lot more detailed information about the emotional, social, healthcare and support needs of each person. This information provides staff with a better understanding of the needs and wishes of each service user and how best support them. Care plans are being regularly reviewed and updated. Service users abilities and limitations are better recorded, this enables the people who are supporting service users to involve them more appropriately in making decisions and choices about their lives.
3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 6 Staff provide service users with more opportunities and experiences helping them to develop their life skills and be more independent. Many improvements have been made to the inside of the home. The bathroom has been refurbished and decorated, other areas of the home have also been redecorated. Furniture in the home has been rearranged to provide more space for the use of service users. The home has more of the required records that are better maintained updated and stored in the correct way. 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. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 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 standard(s) 1 3 5 Information about the choice of home is not detailed enough so prospective service users are unable make an informed choice about living at the home. The information was not available in an accessible format therefore some prospective service users may be unable to access it. Assessment information about the home was incomplete. Unless a full assessment of needs is undertaken before admission, there is no assurance that care needs will be met. Contracts were not signed this would indicate that service users have not agreed to the terms and conditions of the service. EVIDENCE: A Statement of Purpose and service user Guide that was viewed they included some information about the service but not enough to fully inform prospective service users about the home. The homes Statement of Purpose and Service user Guide were written in standard type, a format that one service user was unable to understand. Assessments for both service users were viewed. Assessment information completed by the home did not include enough information about individuals care and support needs. There was no care management assessment on file for one service user. A contract for both service users was available in their individual files. Neither of the contracts were signed or dated by the service user or their representative.
3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 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 standard(s) 6 9 10 Care plans for both service users included a good level of information that was relevant and up to date enabling staff to provide the appropriate care and support for each individual. Care plans were not signed this suggests that service users were not involved in developing them. Risk assessments were not detailed enough putting service users at risk of harm. Information was appropriately stored, to safeguard Service users personal records. EVIDENCE: A care plan was viewed for both service users. They covered relevant areas of service users personal, social support and healthcare needs. One service user talked about the activities and tasks that she is involved in, this information was recorded in her care plan. Care plans are reviewed and updated at regular intervals. The manager and a member of staff stated that care plans are carried out with the involvement of service users and or their representative, there was no evidence to support this. One service user unable to confirm this. A member of staff was observed enabling a service user to take risks as part of her independent lifestyle, for example preparing a hot drink. Although a risk
3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 10 assessment is carried out for this and other activities they do not include enough information about the action to be taken to minimise the level of risks and hazards. Information about service users was kept securely in the home. One member of staff interviewed was clearly knowledgeable about confidentiality, she described what information must be treated with confidence and when and who it must be shared with. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 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 standard(s) 12 13 16 Service users are given opportunities take part in a variety of activities of their choice so maintaining and developing their social, emotional communication and independent living skills. Staff support service users to take part in a variety of activities in the local community in accordance to their plan of care. EVIDENCE: A member of staff was observed involving and appropriately supporting a service user in tasks and activities of her choice. One service user showed off items of artwork that she has produced with the support of staff. The items that were displayed around the home included flower arrangements, paintings and collages. The service user also showed off a photograph album displaying photographs following a recent holiday in Wales, which, was attended, by both service users and staff. The service user stated that she enjoyed the holiday very much and was looking forward to taking another. Care plans included information about service users preferred activities and routines both at home and in the community the information was consistent with the preferred activities described by one service user. One service user attends a day centre one full day a week. Another service user chooses not to take part in any educational or training activities but is given other
3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 12 opportunities to learn and use life skills examples she gave included shopping for household and personal items, making hot drinks and general tidying around the house. During interview the manager and staff demonstrated the importance of enabling service users to take part in valued and fulfilling activities. Staff were observed interacting well with a service user her wishes were respected and appropriately supported. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 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 standard(s) 19 Care plans included a good level of information ensuring that service users physical and healthcare needs are met. EVIDENCE: Both general and specialist health care needs are identified on the care plan. Service users are supported to access healthcare services of their choice, details of services and facilities used by service users are recorded in their individual plans. The information is detailed and up to date. During interview a member of staff was able to describe clearly the health care needs and personal care routines of both service users. One service user who requires cream for a skin condition is encouraged to apply the cream herself, staff provide support with this only when necessary and always in a dignified way. The service user confirmed that she is able to apply the cream with some support from staff. Information on care plans show that both service users are generally in good health. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 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 standard(s) 23 The homes complaints procedure does not include all the relevant information to enable service users to make a complaint in the proper way. Protection of Vulnerable adults (POVA) training has not been completed by all staff to provide the necessary safeguards and protection for service users living in the home. EVIDENCE: The homes complaints procedure was examined it did not include enough information about the stages and timescales involved in the process. The complaints procedure that was available at the home is not written in a format that is easily understood by service users who live there. This was clear during discussion with a service user who was unable to read. All staff have, not completed protection of Vulnerable Adults (POVA) training (known by some people as Abuse). Knowsley’s Local Authorities Protection of Vulnerable Adults Procedure was available at the home. During discussion staff showed that they understand the procedure and are confident about reporting any concerns. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 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 standard(s) 24 30 The home was generally well maintained, clean and tidy providing a safe and homely environment for service users who live there. EVIDENCE: The home was clean and tidy. Service users are encouraged and appropriately supported by staff to maintain a clean environment. Communal areas of the home have been redecorated and furniture has been rearranged to provide more space for the use of service users. One service user confirmed that she was involved in selecting décor and expressed great satisfaction with the improvements. Since the last inspection maintenance programme has been developed which identifies other areas of the home that need attention. As well as identifying the areas the plan also provides details of what needs to be done, when and who by. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 16 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 35 Staff are have not completed all the relevant training to ensure that service users needs are met. EVIDENCE: All staff have not completed required training. The manager confirmed that she is in the process of arranging the required training for all staff to attend. Training that needs to be completed by all staff includes Protection of Vulnerable Adults (POVA), Manual Handling and Food Hygiene. All staff have recently completed medication training. Current staffing levels at the home appear to meet the needs of service users. The competence and ability of staff was demonstrated by the high standard of care and support provided for service users. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 17 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 39 42 Quality monitoring processes are not always being carried out to ensure that service users views about the service are being taken into account. The home is carrying out the necessary checks to ensure the health, safety and welfare of service users. Not all the required Health and Safety policies and procedures are available to inform service users and staff about safety procedures within the home. EVIDENCE: Questionnaires were available for service users to complete. The questions will be used to seek the service users views about the home. No questionnaires have yet been completed the manager stated that representatives of service users will be asked to help service users to complete them. The owner has not carried out monthly visits to the home. Service users views are taken into account one service user said that staff give her choices, are very helpful and listen to her. The majority of the required Health and Safety policies and procedures were available at the home. One member of staff was able to say were they are
3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 18 kept and that she has read them. Certificates of safety checks and details of tests carried out on the environment were viewed at the home. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 19 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 2 x 2 x 2 Standard No 22 23
ENVIRONMENT Score x 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 x x 2 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 2 Standard No 11 12 13 14 15 16 17 x 3 3 x x 3 x Standard No 31 32 33 34 35 36 Score x x x x 2 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
3 Clare Walk Score x 3 x x Standard No 37 38 39 40 41 42 43 Score x x 1 x x x x F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 20 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. 1. Standard YA1 Regulation 4(1)©4(2 ) Requirement The Manager must provide a statement of purpose that includes all the elements in Shedule 1 of the Care Homes Regulation. The manager must provide a service user guide incorporating all the elements described in the Regulation. The manager must ensure that service user contracts are agreed and signed by the service user or their representative. The manager must make arrangements for all staff participate in POVA training. The manager must ensure that a comprehensive assessfment of staff training needs is carried out and that an individual training plan is developed. The provider must carry out monthly visits to the home and provide the CSCI with written reports. The manager must ensure that all records required for the protection of service users and the efficent running of the home are maintained The manager must commence Timescale for action 05/07/05 2. YA1 5(1) 05/07/05 3. YA5 5(1)(b)(c) 05/07/05 4. 5. YA23 YA35 13(b) 18(1)(b) 05/06/05 05/07/05 6. YA39 17(1) 05/06/05 7. YA41 13(4)(a)( b) 05/08/05 8. YA37 10(3) 08/05/05
Page 21 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 9. YA9 13(4)(a)( b(c) 10. YA22 22(1) 11. YA42 12(1)(a) 12. YA40 12(1)(a) 13. YA39 25(1)(2)( 3) 13(6)16(2 )(l) 14. YA23 NVQ Level 4 in management and care. The manager must ensure that all risk assessments include detailed information about the action required to reduce the level of risk. the manager must the complaints procedure and make it more accessible to service users. The manager must provide all the required Health & Safety Policies and procedures that are listed in Appendix 3 of the Care Home Regulations. the manager must provide detailed written policies and procedures covering the topics set out in Appendix 3 of the Care Home Regulations. The manager must obtain a business plan that ensures the effectiveness, financial viability and accountability of the home. The manager must ensure that bank statements for service users and details of payments made to the home by them are kept in their individual files. 05/07/05 05/07/05 05/08/05 05/08/05 05/08/05 Immediate 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. Refer to Standard YA34 Good Practice Recommendations The manager should develop the homes Equal Opportunities and Recruitment and Selection Procedures. 3 Clare Walk F53 F03 S21519 3 Clare Walk V226624 050505 Stage 4.doc Version 1.30 Page 22 Commission for Social Care Inspection Burlington House, 2nd Floor, South Wing 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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