Inspection on 06/02/07 for Freshfield Cheshire Home

This inspection was carried out on 6th February 2007.

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

Other inspections for this house

Freshfield Cheshire Home 09/02/06

Freshfield Cheshire Home 27/05/04

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 Freshfield Cheshire Home College Path Freshfield Formby Merseyside L37 1LE Lead Inspector Mrs Joanne Revie Key Unannounced Inspection 6th February 2007 10:00 Freshfield Cheshire Home DS0000017236.V320669.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 Freshfield Cheshire Home DS0000017236.V320669.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. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Freshfield Cheshire Home Address College Path Freshfield Formby Merseyside L37 1LE 01704 870119 01704 834408 julie.perry@lc-uk.org www.leonard-cheshire.org.uk Leonard Cheshire 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) Mrs Julie Anne Perry Care Home 35 Category(ies) of Learning disability (3), Physical disability (32) registration, with number of places Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Service users to include up to 32 PD and up to 3 LD. Maximum no. registered - 35, of which up to a maximum of 30 PC (personal care) and up to a maximum of 12 N (nursing). Date of last inspection Brief Description of the Service: Freshfields is owned and operated by the Leonard Cheshire Foundation. It is registered to provide nursing and personal care for adults with physical disabilities. The home is also registered to provide a service for three adults with learning disabilities and one planned respite placement. A Day care facility is available within the home that provides a service to residents as well as members of the local community. Accommodation in the home is provided in a variety of settings. Single rooms are available in the large section of the building whilst double and single selfcontained flat like rooms are available in the extensions that are linked to the main building. A large part of the home is purpose built and provides modern facilities. Freshfields is located in a highly popular residential area of Formby. The home is accessed via a private road and shares grounds with another residential care home. Local shops, pubs, and other facilities are within walking distance of the home. Public transport links are also easily accessible. The home is close to the local railway station of Freshfields, Formby. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over two days. Prior to the inspection questionnaires were sent to residents who live within the home. 19 completed questionnaires were returned for scrutiny. Discussions took place with residents who live there, and staff during the visit. Their views are included within the summary section of the report. A variety of documentation was viewed and a tour of the premises was undertaken. These areas are referred to in the evidence section of the report. The manager provided other written information prior to the visit known as a pre inspection questionnaire. This has been taken into consideration when judging evidence. Whether the service promotes equality and diversity was considered during the visit. Four residents were case tracked. This means that the visit focused on these four persons experience of what it was like to live at the home. The outcome for this showed that the service does promote persons individuality by supporting them to lead the lifestyle of their choice. The service has been commended for this in the relevant section within the report. What the service does well: The admission process to the home is a smooth transition as many residents have spent time at the home previously for respite. This means that they know what to expect and staff know the support they require which makes the process less worrying .New residents who have never used the service are also given opportunities to spend time at the home before they decide to move in. This enables people to make an informed choice. The home has a very strong community spirit. One resident commented that “It’s like one big family- you have your good days and bad days and then you make up again like any family”. Residents are involved and consulted in all aspects, which affect their daily lives. A resident commented that “ Its dead relaxed here – you can do as you please” A residents committee exists and residents are involved on the Homes health and Safety committee also. Residents are provided with training so that they are able to interview prospective staff for the service, which promotes further ownership and empowerment. The home provides a variety of activities at different times of the day. A day centre is run from the service also and if residents wish they could join in the activities on offer there also. The home has transport, which is suitable for Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 6 wheelchairs, and also benefits from a craft room, which is fitted with a kiln for pottery. The home provides a good standard of home cooked food, which is nutritious. A resident commented that “The foods very good, we get a choice of six breakfast cereals, and two choices of meals every lunch and tea time- They make supper for you as well if you want, But I don’t bother - I have my own fridge and kettle”. Several of the bedrooms viewed contained kettle’s fridges and microwaves. Some residents have larger rooms which they have furnished like a bed sit. Some have smaller rooms with en suite showers and some have flats. In general the home presents as a clean comfortable spacious place to live. The home is equipped with a coffee bar for the residents and visitors use. Plans are underway to refurbish this area. The residents also manage and run a small shop for sweets, toiletries etc. Staff support residents to manage health care needs well and despite the size of the home are successful in providing individualised care and support. Residents commented that “Staff are good, good kids – they look after me well” and “The staff are great – Im really fond of some of them” and “There’s nothing Im not happy with” The staff are supported by large team of volunteers, which means that there is always someone available to support residents to undertake individual activities. The service employs a dedicated staff team who have access to training to care for the residents but also for their own personal development. Approximately 75 of the staff have achieved NVQ qualification, which is greater than the national minimum recommended standard. What has improved since the last inspection? The residents committee has expanded to ensure all residents are included by each committee member acting as a spokes person for a further three residents who live in the home. This means that all residents are involved in consultations. Staff have worked hard to make care plan documentation more individual for each resident. This means that staff who may not know the residents well have clear written instructions to follow about their needs, likes and dislikes. The activities organiser has undertaken training to ensure residents are safer when they use the homes transport and staff have continued to attend on Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 7 going mandatory training to ensure that the resident’s health and welfare is promoted. The home has adopted a monitored dosage system which helps to reduce the risk of a medication mistake being made and staff have undertaken training in this area. The manager has completed a large self-audit exercise, which is very good practise and shows that the service is open to self-criticism. All volunteers undertake the induction programme, which is designed for staff so everyone within the service has a basic understanding of their role and responsibilities. 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. The summary of this inspection report can be made available in other formats on request. Freshfield Cheshire Home DS0000017236.V320669.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 Freshfield Cheshire Home DS0000017236.V320669.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. JUDGEMENT – we looked at outcomes for the following standard(s): 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents have their needs fully assessed before admission takes place and are given opportunities to spend time at the home before a decision to move in is made. Residents believe they are provided with sufficient information to make a choice EVIDENCE: 19 questionnaires received all agreed that they had received sufficient information to enable them to make a choice about moving into the home. A resident who recently moved to the home was case tracked. Viewing care plans showed that staff have access to assessment information within this. The information provided was clear and gave a good overview of the residents needs. The manager explained that more often than not residents are known to the service as often they have been staying at the home for respite care. This had been occurring for several years in the case of the resident who was case tracked. A discussion with the resident showed that he had been consulted and involved in all parts of the admission process and that he was fully aware of what the home offered due to the previous respite periods. He stated that staff had been helpful and supportive in helping him settle in and that he had quickly developed his own daily routine. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 10 Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 11 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good Staff have developed care plans, which clearly reflect the individual needs and choices of the residents. Residents” feel in charge” of their lives and are actively encouraged to make the home their own. Residents are supported to lead as independent lifestyle as possible and staff recognise and support risk taking. EVIDENCE: Three residents were case tracked and four care plans were viewed. The opinion reached was that three of the four plans viewed met the national minimum standard required. Discussions with a qualified nurse and the manager revealed that although this is the case, work is still going on to develop the plans further. The manager explained that staff had worked hard since the last inspection to make the plans more personal to each resident. This was clear when the plans were viewed as time had been taken to write all needs, problems and preferences in the first person. This gave the reader the impression that the information had been written by the residents and not the staff, which helped to give a very clear pen picture. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 12 Time has been spent in particular in recording detailed preferences. Examples of this were viewed around personal care giving. Detailed explanations were viewed which showed exactly what the residents was able to do and wished to do for them selves and the exact amount of input and support that was required by staff. The plans contained a great deal of information. As well as specific needs documentation is in place which shows that staff have considered risks that the residents would take as part of their daily life as well as risks which may be associated with health care. These documents were found to be completed to a good standard. Staff commented that further work was to be undertaken on these as other staff had commented that they felt in some instances as if they trying to squeeze the residents in to boxes rather than developing boxes around residents indivual needs. This reflects good practise and shows that staff recognise the importance of treating residents as individuals. One plan was viewed for a resident who had been recently admitted to the home. This was brief and was not completed to the expected recommended standard. Viewing supervision records showed that the member of staff who was responsible for this had been reminded of their responsibilities and a senior member of staff was monitoring progress. The residents had signed all plans viewed and plans appeared to be being reviewed every three to four months. This is greater than the recommended national minimum standard. The manager stated that she has made contact with the person who developed the ISP (care plan) to visit the home to give further advice and guidance to staff regarding their development. Discussions were held with five residents. All agreed that they were in charge of their life and that staff supported them to lead their lives as they wished. A discussion with residents, the manager and viewing minutes revealed that the residents have a residents committee. A member explained that each committee member is responsible for relaying information and seeking views from another three residents within the home. Therefore the committee acts fairly by trying to ensure all residents who live at the home have their say. Viewing other minutes also showed that Committee members are involved with other metrtings within the home such as Health and Safety. On the day of the visit residents had arranged to meet to discuss a forthcoming petition, which they wished to raise to the local council regarding safe suitable routes to use to access the local village for people who are wheelchair users. No staff were involved in this meeting. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 13 One resident confirmed that they had spent time away from the home learning how to interview staff so that they could be involved in future decision making when employing new staff. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,15,16,17 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents take part in a variety of activities of their choice in and outside the home. Staff are welcoming to visitors Residents are encouraged and supported to lead their own lives Residents are offered a nutritious diet and are supported to have their own personal food and drink supplies if they wish. EVIDENCE: All residents spoken with during the visits agreed that there is a good variety of activities on offer and that the staff will support them to undertake an activities that they wish .The home employs an activities coordinator. Records viewed showed that residents take part in a variety of activities inside and outside the home. Sometimes there are group activities and sometimes these Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 15 are individual. Care plans viewed gave clear details of how each resident preferred to spend their time and the level of support required to achieve this. A day centre is run from the home, which has its own staff team. Residents are welcome to join in the daily activities offered if they wish. The home has its own craft room, which was viewed so activities such as pottery and painting can be easily undertaken. A tutor is available who was on site during the visit for this purpose. The home also has an area, which has been set out as a computer suite. Staff from Hugh Baird College visit the home once a week to provide on site training. One resident revealed that she had her own computer in this area also. The home also has a large quiet lounge, which was viewed and is also used to house a large video collection. The manager stated that Residents are encouraged to borrow any films they wish from this. The home has suitable transport available for group activities and the activities coordinator has recently completed MIDAS training to ensure that the bus is operated safely. A discussion with the manager also evidenced that residents are supported to go on holiday and several residents regularly visit home with relatives- this was confirmed in two care plans viewed. The home has a small shop. This is organised and run by residents (including accounts). A committee member confirmed this during discussions. This means residents can purchase small items such as sweets and toiletries within the home. Discussion with three residents revealed that they all received regular visits from family members. All agreed that staff welcomed their visitors and that visitors were free to visit whenever they wished. Viewing the visitors book confirmed that the home has an open visiting policy. Menus were viewed within the home and a mealtime was observed. A calm atmosphere had been promoted and staff had ensured that the dining room was equipped with condiments etc and presented nicely. Staff provided support in a dignified manner and were overheard offering residents choice. All residents spoken with including the nineteen questionnaires agreed that the food offered was of a good standard. All residents spoken with (5) agreed that they were offered choices at each mealtime. Touring the environment evidenced that several residents also have fridges and microwaves and tea making facilities in their bedrooms for in between meal and for entertaining their visitors. The home has a coffee bar, which is open to residents and visitors. Plans have been developed to alter the structure of this so that is accessible to more residents. The menus viewed evidenced that choices are available at each mealtime and that residents are offered a nutritious diet. The meal served during the visit looked appetising and was nicely presented. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18,19,20 Quality in this outcome area is adequate This judgement has been made using available evidence including a visit to this service. Residents receive personal support how they prefer Staff support residents to remain healthy Medications are not managed as safely as they could be and the storage of medications requires urgent attention. EVIDENCE: Four care plans were viewed. These gave very clear details of the personal care required and preferred by each resident and included which gender of staff residents preferred to receive care and support from. 19 questionnaires received all agreed that staff treat them well. Discussions with five residents confirmed that staff respect residents privacy and dignity. Four care plans were viewed. Health care needs had been specified and reviewed regularly within the plan. Each plan contained details of visits from other health care professionals. Viewing daily records revealed that staff had acted on their recommendations. During both days of the visit residents were seen being supported by staff to attend hospital visits. Nursing staff are Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 17 employed within the home to undertake nursing duties for those residents who require their input. Wound acre records were viewed for one resident. These showed that staff were promoting healing by treating of the wound however no photographs or wound mapping tool had been used as further evidence. Requirements were made following the last inspection in relation to medication. Staff have had training as evidenced in the training section of this report how ever one requirement, which related to record keeping has not. The manager was `disappointed that this had fallen down as efforts had been made to address this concern. MARS showed that some signatures were missing on some records, which meant it, could not be determined whether residents had received medications as prescribed or not. In particular signing of the administration of creams was inconsistent. The manager stated that care staff often administer this and may be reluctant to sign the MAR so the qualified nurse was inclined to tick the box rather than sign. The service has implemented a monitored dosage system since the last inspection, which is good practise as it helps to reduce the risk of a mistake occurring. The service has a small storage room for extra stock. On the day of the visit this was very warm (34 degrees). Medications should not be stored at temperatures greater than 25 degrees. One metal cabinet, which was being used to store medications felt warm to touch as did the wall, it was attached to. A bottle of gaviscon was felt which was being stored in the cupboard also felt warm to touch. This wall has a radiator attached to it on the other side, which was on. The qualified staff on duty stated that they were aware of this problem but a local pharmacist had visited the service in the past and had never commented on this problem, so no action had been taken. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22,23 Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. Residents are confident that their concerns are listened to Residents are protected from abuse. EVIDENCE: All nineteen questionnaires received stated that the residents knew who to complain to. Copies of the services complaints procedure were displayed around the home and where also available in the Porch. The homes complaints records were viewed. These showed that complaints are acted on and investigations are undertaken. Complainants receive written outcomes in line with the homes own policy. Viewing staff files and the training matrix showed that staff undertake training on abuse awareness and protection of vulnerable adults. This is also covered in the induction period for new staff. Discussions with residents revealed that they believe they are safe at the home and that they can trust the staff. Discussions with staff revealed that they knew what to do if they suspected abuse had occurred. Records were viewed which related to some resident’s personal allowances. These `were found to be managed well with a clear visible audit trail. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24,30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in a warm, clean, comfortable home, which is well maintained EVIDENCE: Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 20 A tour of the environment was undertaken. The home has large spacious well-maintained gardens that are furnished with wooden garden furniture. Residents who have access from their bedrooms to the gardens have their own patio furniture, which makes extra outdoor living space for them in warmer weather. A large car park for use of staff and visitors is located at the front of the home. There are several spacious lounge areas and a large dining area that is central to the home. This includes a quiet lounge and separate smoking lounge A large function room is also available. One end of the room is currently equipped with computers and other IT equipment. The home’s main kitchen is situated close to the dining area. There is a smaller kitchen also close to the dining room known as the coffee bar. This is equipped with facilities to enable residents to prepare drinks and snacks and has a lowered work surface so it’s accessible for people who use wheelchairs. Plans have been developed to redesign this to make it more accessible. The homes laundry is situated separately and contains industrial washing machines and dryers. The laundry is kept locked when it is not in use. . The home provides a variety of aids and adaptations to meet resident’s needs. These include walks in showers, specialist baths, handrails, hoists, overhead tracking hoists and lowered work surfaces. All bedrooms are fitted with a call system. The call system was examined and found to be in good working. Records examined on the day of the visit evidenced that a competent person regularly inspects all equipment in the home. . During the inspection the home presented as a clean, warm, comfortable place to live. Viewing rotas evidenced that the home employs a dedicated team of domestic staff. All furnishings viewed were of good quality. The manager produced a list of rooms that the occupants had stated were available to be viewed. This reflects good practise and is further evidence of residents being offered choice. All bedrooms viewed (7) were personal to the residents and were furnished with personal affects of their own choice. Some residents had chosen to furnish their bedrooms with microwaves, fridges kettles etc. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 32,33,34,35 Quality in this outcome area is excellent This judgement has been made using available evidence including a visit to this service. Staff have the skills and receiving the training they need to care and support the residents Residents are supported by an effective staff team, which is further supported by a large group of volunteers The service has robust recruitment procedures EVIDENCE: A sample of staff rotas were viewed. This showed that the staff team undertakes flexible shifts to enable the residents to have staff available when they need them most. Viewing the rotas showed that time is identified when staff can expect to receive 1:1 time (supervision) with their allocated supervisor. Viewing staff files evidenced that this occurs. The home also accepts occupational therapy students on placement from a local university. Support is also provided from a large group of volunteers some of who are from overseas. 4 staff files were viewed and also three files for volunteers. All of these contained the information required to meet the care home regulations 2001 Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 22 and showed that the home undertakes these necessary checks before employment commences. The volunteers are involved in many aspects of life at the home such as help with meals, assist at the day centre, gardening taking residents out etc. A training plan was viewed and provided which showed that staff undertake mandatory training to enable them to maintain the residents health and welfare. More specialist training is provided according to the residents needs and the manager stated that if staff show a particular interest in a subject then more often than not support is made available for them to undertake this also. The organisation has a training department, which staff attend to undertake mandatory training and induction training. Staff are paid to attend training and receive travel expenses also. The rota showed that nineteen staff and 8 registered nurses are employed at the home. 11 staff have achieved NVQ qualifications, which means 19 of the 27 care staff, have appropriate qualifications in care. The policy of the organisation is that it is mandatory for staff to undertake NVQ or equivalent qualifications. A discussion took place with the NVQ coordinator for the service who explained that the service has its own assessment centre for NVQ candidates. . Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 23 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. JUDGEMENT – we looked at outcomes for the following standard(s): Quality in this outcome area is good. 37,39,42 This judgement has been made using available evidence including a visit to this service. The home is well run Resident’s opinion affects the delivery of the service. The service acts responsibly toward maintaining residents and staff s Health and safety. EVIDENCE: The home has registered manager who is registered with CSCI. The manager stated that she has achieved a certificate in management and is waiting to be awarded an NVQ level 4 in management following completion of 3 NVQ units. A copy of the Quality assurance audit for last year (06) was viewed. The manager explained that this is undertaken annually. The manager has recently completed a self-assessment of the service, which reflects good practise. The Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 24 manager stated that this going to become an annual occurrence as well. Any findings from either of the above processes are discussed in the first instance at residents meetings so that an agreeable action can be taken. Residents meetings regularly occur (minutes viewed) as well as residents committee meetings. Minutes were viewed which showed that usually Health and Safety meetings are held three monthly and that these are represented by a nominated resident also. A variety of certificates and contracts were viewed. These showed that all equipment in use within the home (including call bell and fire safety equipment) is serviced annually and regularly tested as required. No Health and Safety hazards were identified during the visit. During the visit the fire alarm sounded unexpectedly. Staff were observed to act appropriately in a calm unhurried manner. Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 25 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 3 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 3 33 4 34 3 35 4 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 4 X 3 X LIFESTYLES Standard No Score 11 X 12 4 13 4 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 4 X X 3 X Freshfield Cheshire Home DS0000017236.V320669.R01.S.doc Version 5.2 Page 26 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 YA20 Regulation Requirement Timescale for action 31/03/07 17(1)Schedule Medicine Administration 3 3(i) Records (MAR) sheets must be completed according to the homes Policies and Procedures. Outstanding. Should have been completed by 09/02/06 13.2 Medications must not be stored at temperatures greater than 25 degrees 2 YA20 31/03/07 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 YA19 Good Practice Recommendations In the interests of best practise staff should consider taking photographs or using wound mapping as further evidence of effective wound care. Freshfield Cheshire Home DS0000017236.V320669.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: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Freshfield Cheshire Home DS0000017236.V320669.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. 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