CARE HOME ADULTS 18-65
21 Coachmans Drive 21 Coachmans Drive Croxteth Park Liverpool L12 0NX Lead Inspector
Beate Roth Unannounced 6 June 2005 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. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION
Name of service 21 Coachmans Drive Address 21 Coachmans Drive, Croxteth Park, Liverpool, L12 0NX 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) 0151 220 9729 Community Integrated Care PC Care Home Only 3 Category(ies) of LD Learning Disability 3 registration, with number of places 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION
Conditions of registration: None Date of last inspection 16/12/04 Brief Description of the Service: 21 Coachmans Drive is registered to provide care for three adults with a learning disability, at present there are only two service users living at the home. Service users have single bedrooms, there is a large lounge that contains a dining area, a bathroom with bathing aids, kitchen and an office. There is a private, enclosed garden to the rear of the house and an open plan front garden and driveway. There is wheelchair access to the property. The home is situated in a quiet residential area in Croxteth Park. The home beneifts from having a mini bus, there is also a local bus service within walking distance. There are shops, parks, pubs and restaurants in the area. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over a morning. During the inspection time was spent in the office examining records and policies and procedures and talking to the acting manager. A tour of the home was undertaken. Staff were observed delivering care to service users. A member of staff was spoken to. What the service does well: What has improved since the last inspection? What they could do better:
There are several areas in which improvements need to be made for the benefit of the service users. All care planning documentation relating to the health and safety of service users must be fully documented and subject to a regular review. The records of staff recruitment must be available at the home for inspection and must contain all the required information in order to show that the staff working with service users are competent and suitable to care for vulnerable adults. Regular supervision needs to be provided for staff so an overview of their training and developmental needs can be maintained. Improvements need to be made to the training records held at the home so that it is evident trained and skilled staff are supporting service users. Service users who have no family contact would benefit from the use of independent advocates. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 6 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. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 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 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 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 and 5 Information is available to enable a representative to make a choice about whether the service user should live at the home. The assessed needs of the service users are met. The use of advocacy services would better promote the welfare of some service users. EVIDENCE: A service users guide has been made available since the last inspection. This contains the required information. Consideration could be given to making the guide more suitable to the needs of the service users living at the home. It is acknowledged that the current service users may not benefit from this. The records indicated that consultation with relevant agencies such as community nurses, dieticians, G.P’s and chiropodists takes place. Service users have access to hoists and wheelchairs and specialist equipment. There is information around the communication needs of service user in their care plans. It is recommended that this be expanded upon. Service users would perhaps benefit from personal communication dictionaries. Steps are being taken to ensure that the staff have a qualification in caring for adults with a learning disability. One member of staff has an NVQ Level 2 and 4 of the staff are currently undertaking this qualification. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 9 The service users have a tenancy agreement with Maritime Housing. A copy of the contract between the service user and Community Integrated Care was also available. A relative has completed the contract for a service user. Senior staff from Community Integrated Care have signed the contract for the other service user. It is recommended that an advocate be approached regarding agreement to this contract given that they are not directly linked to the organisation providing the service and can view the contracts objectively. The contract asks service users if they agree to paying a contribution towards the cost of the mini bus. The agreement of service users or their representatives is not indicated, although they are both paying a contribution. It is suggested that an independent relative or advocate is involved to make sure the monies spent on the home’s minibus is the best use of their money. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 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 standard(s) 6, 9 and 10 The needs of service users are not promoted by the home’s practices regarding risk assessments. The home’s practices around maintaining confidentiality ensure that the privacy of service users is promoted. EVIDENCE: The care plans and essential lifestyle plans were inspected for the two service users living in the home. The information they contained was useful and relevant to their needs. The care plans had been reviewed monthly and updated accordingly. The essential lifestyle plans were due for a review, the reviews are planned, this will include the involvement of family and relevant professionals. Since the last inspection a special night-time harness has been made available for a service user. The guidelines for the use of the harness have been drawn up by the occupational therapist, with involvement from the health and safety officer from Community Integrated Care, the service users family and staff. All staff have received instruction around this. The guidelines for the use of the harness refer to having scissors located in the bedroom so that the service user can be removed from the harness in the event of a fire. At the time of the inspection, scissors were not available in the location indicated in the
21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 11 guidelines. The acting manager attended to this immediately. The guidelines for the use of the harness had not been reviewed since they were introduced in January 2005. A risk assessment for the use of the harness must be devised and a weekly review of this assessment undertaken. Risk assessments are carried out for both personal and environmental risks. A sample were seen and had been reviewed and updated. It was identified that a risk assessment for taking a service user canoeing is needed as this is an activity currently undertaken by the service user. Confidentiality is maintained at the home by giving training to staff during their induction period on the importance of maintaining confidentiality and good record keeping. All documentation relating to the service users is kept securely in the home and the premises is alarmed. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 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 standard(s) 12, 13 and 16 Service users are able to take part in appropriate activities and are part of the local community. The staff team support service users to maintain their levels of independence. EVIDENCE: Neither of the current service users take part in any employment nor do they attend college. However, they are both encouraged to pursue individual hobbies, for example one of the service users likes to go canoeing. Other activities are on offer such as visiting the local sensory room, going to the theatre and helping with household tasks such as shopping. The staffing levels allow for individual and group activities to take place. The records and a discussion with staff indicated that service users make use of the local community by using shops and parks, local museums and local pubs and restaurants. Service users from a small Community Integrated Care home nearby visit the service users and it is hoped this can be developed and reciprocal visits made to their home. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 13 During the visit the inspector observed the acting manager and a member of the staff team supporting service users in a respectful and friendly manner. Members of the staff team were able to show they had a good knowledge and understanding of the service users needs. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 14 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19 and 20 The homes practices around medication management, in general, support the needs of service users. EVIDENCE: Records indicate that staff support the health care needs of service users and that medical interventions are sought as and when necessary. A care plan is available regarding the management of a service user’s epilepsy. This refers to staff being on duty and does not take into account the arrangements at night time when there is only one waking member of staff on duty. None of the current service users self medicate. Policies are in place to support staff to assist any service users who wish to self medicate. The medication administration records and corresponding medication were inspected and found to be accurate. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 15 Concerns, Complaints and Protection
The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 The service users and their representatives could benefit from the home’s complaints procedure being more user friendly. EVIDENCE: The home has a detailed complaints procedure with timescales for action and responses to concerns raised, however this documentation is lengthy and not user friendly. Staff spoken with were aware of the complaint procedure and what to do if they are approached with a complaint. No complaints have been made to the Commission for Social Care Inspection about the home since the last inspection. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 16 Environment
The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 and 30 The home is well presented and provides a comfortable and pleasant environment for service users. EVIDENCE: 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 17 A tour of the home indicated that the home is in general, well maintained. The home is comfortably furnished and has a homely, domestic appearance. The bedrooms provided for service users are single, these are adequately sized and enable the service users to be moved around the room in wheelchairs. There is a large lounge/dining room and a bathroom. The bathroom and toilet facilities are adequate, however the appearance of the bathroom was worn and dated and it is recommended that it is refurbished. Bathing aids are provided. The kitchen is a good size and is fully fitted. The washing machine and dryer are housed in a utility room away from the main part of the home. It continues to be recommended that consideration is given to moving the fuse box inside the house to ensure that both service users and staff are safe. At present the staff have to go outside into the garage if the electricity fails to operate the trip switch. This leaves the service users vulnerable at night as there is only one member of staff on duty. All of the communal rooms used by service users are on the ground floor, access to and from the front and back of the house was satisfactory and service users have freedom of movement around the home. The home was clean, odour free and the standard of housekeeping on inspection was very high. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 18 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 33, 34, 35 and 36 There are sufficient staff to meet the needs of the service users. The recruitment practices at the home do not support and protect service users. Service users would benefit from staff having regular supervision. EVIDENCE: Following the last inspection the home was required to provide the CSCI with a copy of the rota so that the staffing levels could be monitored. At this inspection there has been improvements to the staffing arrangements as 4 new staff have been employed. There are still vacancies for 1 full time and one part time member of staff. Bank or existing staff are covering shortfalls. The same bank staff are being used to ensure continuity. The rota indicates that there are 2 staff on duty during the day and evening and 1 waking member of staff through the night. The rota indicates that some staff are working 50 hours per week, there was no record of staff having completed an agreement with their employer to indicate their willingness to work such hours. 4 new staff have been employed since the last inspection. The records of recruitment relating to these staff were examined. There were no recruitment records for one member of staff. The acting manager reported that these records are available but have not been transferred from head office.
21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 19 Documentation to confirm identity was not available for the three other staff, there were no references for one member of staff and no documentary evidence of a CRB/POVA check having taken place before one of the members of staff began working at the home. Community Integrated care has its own training department which offers a variety of training to staff. Some certificates of training were available on the staff files. This indicated that some staff have received training in moving and handling, food hygiene and first aid. However, a true reflection of the current training staff have received could not be ascertained as not all the training certificates were available. An audit of the training needs of staff is to be undertaken and action taken to ensure all staff have received up to date training in first aid, manual handling and food hygiene. The lack of supervision at the home has no doubt contributed to this information not being available. Steps are being taken to ensure that the staff have a qualification in caring for adults with a learning disability. One member of staff has an NVQ Level 2 and 4 of the staff are currently undertaking this qualification. At the last inspection a requirement was made that staff are to be given the opportunity to take part in supervision sessions with their line manager at least 6 times a year. The acting manager has only been in post for 2 weeks. No supervision has taken place since the last inspection. The acting manager has not received training around providing supervision. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 20 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) 37 and 42 The health and safety needs of service users could be better promoted by the home’s training practices. EVIDENCE: The acting manager has been in post for 2 weeks. The competence of the acting manager cannot therefore, at this stage be assessed. The acting manager has worked at the home for 16 months as a support worker and prior to this was a senior carer at another residential service. The acting manager has completed an NVQ Level 2. An application needs to be made to CSCI to register the acting manager. The records of fire safety checks were in order. The records showed that all staff apart from one have received fire safety training within the recommended timescales. There is written information for staff on how to make sure they protect the health, safety and welfare of service users. As already indicated a true reflection of the current training staff have received could not be ascertained as not all the training certificates were available. An audit of the
21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 21 training needs of staff is to be undertaken and action taken to ensure all staff have received up to date training in first aid, manual handling and food hygiene. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 22 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 x 3 x 2 Standard No 22 23
ENVIRONMENT Score 3 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10
LIFESTYLES Score 3 x x 1 3
Score Standard No 24 25 26 27 28 29 30
STAFFING Score 3 x x x x x 3 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 2 1 2 1 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21
21 Coachmans Drive Score x 2 3 x Standard No 37 38 39 40 41 42 43 Score 2 x x x x 2 x F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 23 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 9 Regulation 13 Requirement The registered person is required to ensure the safety of service users by carrying out a risk assessment for all situations that pose a potential risk to their well-being. A risk assessment for the use of the harness must be devised and a weekly review of this assessment undertaken. The care plan around the management of a service users epilepsy must indicate the arrangements at night time when there is only one waking member of staff on duty. The registered person is required to ensure that copies of recruitment files for all personnel that work at the home are provided for inspection(Previous timescale of 31/01/05 not met). The records of recruitment must contain all the information detailed in Schedule 4 of The Care Homes Regulations 2001. An audit of the training needs of staff must be undertaken and action taken to ensure all staff have received up to date training in first aid, manual handling and
F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Timescale for action 06/06/05 2. 9 13 06/06/05 3. 19 13 06/06/05 4. 34 19 06/06/05 5. 34 17 06/06/05 6. 35 18 06/07/05 21 Coachmans Drive Version 1.30 Page 24 food hygiene. 7. 36 18 The registered person is required to ensure that staff are given the opportunity to take part in supervision sessions with a line manager at least six times a year(Previous timescale of 31/01/28/02/05 not met). The registered persons must ensure an application form is forwarded to CSCI with regard to the registering of a manager within the stated timescale. The registered person must ensure that fire training is provided to day staff on a 6 monthly basis and night staff on a 3 monthly basis. 06/07/05 8. 37 8 06/07/05 9. 42 24 06/06/05 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. Refer to Standard 1 3 Good Practice Recommendations The service user guide could be made more suitable to the needs of prospective service users. Further written information around communication should be made available for staff to ensure that they and future staff can as far as possible communicate effectively with each service user. The registered person should consider the introduction of an independent advocate for the service user who does not have family members to act on their behalf. It is recommended that consideration is given to moving the fuse box inside the house to ensure that both service users and staff are safe during the night shift. The appearance of the bathroom was worn and dated and it is recommended that it is refurbished in keeping with the rest of the décor at the home. The service users and their representatives could benefit from the home’s complaints procedure being more user friendly. Staff should complete an opt out agreement before
F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 25 3. 4. 5. 6. 7. 5 24 24 22 33 21 Coachmans Drive 8. 36 working hours that exceed 48 hours (Working Time Regulations 1998). The acting manager is to receive training around providing supervision to staff. 21 Coachmans Drive F52 F02 S25240 21 coachmans Drive V231841 060605 Stage 4.doc Version 1.30 Page 26 Commission for Social Care Inspection Liverpool Office 3rd Floor, 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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