Inspection on 26/04/05 for Life Works Community Ltd

This inspection was carried out on 26th April 2005.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Life Works Community Ltd 09/07/07

Life Works Community Ltd 09/05/06

Life Works Community Ltd 11/08/04

Life Works Community Ltd 23/06/04

Similar services:

Prinsted

Elizabeth House

Kenward House

Boons Park

Winthrop Hall

Extracts from inspection reports are licensed from CQC, this page was updated on 09/07/2008.

CARE HOME ADULTS 18-65 Lifeworks Community Ltd The Grange High Street Old Woking Surrey GU22 8LB Lead Inspector Kerry Fell Unannounced 26 April 2005 12:45 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. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Life Works Community Ltd Address The Grange High Street Old Woking Surrey GU22 8LB 01753 869777 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) Life Works Community Ltd Mrs Angela Clark Care Home 24 Category(ies) of A Alcohol depend past/present 24 registration, with number D Drug dependence past/present 24 of places MD Mental Disorder 24 Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: Of the twenty-four (24) service users, up to three (3) may be accommodated for a de-toxification programme, which requires nursing intervention. Date of last inspection 11 August 2004 Brief Description of the Service: Life Works Community Ltd is situated in The Grange, a grade ll listed building in the Old Woking area of Surrey. The property is set in two acres of mature gardens. The property consists of 7 shared occupancy bedrooms suitable for meeting the needs of service users with substance addictions, compulsive behaviours, trauma, co-dependency and dual diagnosis (addiction and depression/anxiety). Suitable measures have been taken to ensure service users privacy at all times and CCTV cameras are utilised to monitor the external areas of the property. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first Inspection for the Inspection year 2005/2006. The Inspection was an unannounced Inspection following the receipt of a complaint by CSCI Surrey Local Office. This means that neither the staff nor the service users knew that the Inspection was going to take place. Mrs Kerry Fell and Mrs Catherine Campbell Ace completed the Inspection. People staying at Life Works like to be known as clients, this is the term that will be used within this report. There were only four clients receiving treatment at the time of the Inspection, one of who was happy to talk to the Inspectors. The Inspectors also looked at staff files; client records, policies and procedures, the statement of purpose and the inspectors interviewed one member of staff. What the service does well: What has improved since the last inspection? The level of detail in care records had gradually improved since the last inspection, but there were still areas for improvement (please see comments below). Staff personnel files had improved and were seen to contain all of the information and evidence of recruitment checks that would be expected to safeguard the clients. The Manager showed the Inspectors a very detailed quality assurance programme that they were in the process of introducing. This would involve selected members of staff who would complete a checklist of how well the Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 6 service was performing in relation to the National Minimum Standards For Younger Adults, in order to recognise areas for improvement. 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. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 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 Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 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) 1,2 and 5 The Statement of Purpose was detailed and informs prospective and existing clients, about the service provided. Some pre-admission assessment takes place, along with detailed medical and clinical assessments ensuring that clients’ needs are identified. EVIDENCE: The Inspectors saw the statement of purpose during the inspection. This was a detailed document that was in three main sections - a general introduction to the service, a client handbook, family information and staff handbook. However the statement of purpose had not been updated since the new Manager was registered, so this document must be reviewed in line with Schedule One of The Care Homes Regulations 2001. The document was also not dated so it was not clear when it was last reviewed. The statement of purpose must be reviewed and updated. Most clients are privately funded and can refer themselves to Life Works Community. One client met during the inspection stated that they had previously been a client and had been readmitted to the service a few days prior to the Inspection. The client stated that there was a degree of assessment prior to admission as part of the referral process, however for their most recent admission staff had assessed their needs on arrival and had implemented an intensive support package for them for their first night. The client confirmed that this had since been reviewed and adjusted as required. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 9 Referral documentation and admission assessments were observed on records for clients who had been discharged. These were seen to include health assessments, social assessments, mental health assessments and records of family history. The Inspectors observed signed copies of detailed contracts on client files, and a pro-forma of this contract is available in the client handbook. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 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) 6,9,10 Care plans had improved, however elements of these care plans, treatment plans, and risk assessments required further improvement. Confidentiality was paramount in the ethos of the service. Both clients and members of staff were aware of this ethos. EVIDENCE: One client spoken to during the Inspection stated that they were aware that they had a care plan in place, and that they could get access to it if they so wished, but as they felt that their needs were being met they were not concerned about reading it. The Inspectors requested a selection of care plans for clients, some of these care plans were for clients who had already been discharged. One had been discharged 10 months ago, one was a current client, and others had been discharged in the last three months. The most recent care plans contained the most detailed information, however, there did not appear to be a pro-forma for the treatment plans, which clearly and succinctly detailed what the client’s needs were and what their treatment programme would be. It was also not possible to clearly track any changes in need as the client’s treatment Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 11 progressed. The Manager advised the Inspectors that the activity plan detailed in the client handbook was the arranged plan for all clients. This did not reflect the statement within the Life Works Community terms and conditions which stated that full care that is appropriate and individual to the needs of the Client will be planned and delivered and that care needs will be continually assessed and care plans amended appropriately. Separate clinical notes were also kept. Life Works must ensure that individual care plans are developed and where appropriate are agreed with the client. These plans must reflect the information detailed under Standards 2 and 6 of the National Minimum Standards for Younger Adults. Life Works would also be advised to use a standard template and continual care recording for clarity and continuity of information. Some records had been typed and these had not always been signed and dated by the author. Care plans sampled were not always in a single format, and the Manager advised the Inspectors that the clinicians held some of this information. If records are typed these records must be printed, signed and dated as they are completed. Life Works would be advised to review the number of care records held by different members of staff and must ensure that all records are held on the client’s file. The Manager advised the Inspectors that clinical staff also kept meeting records. These were not seen during this inspection and will be looked at in more detail at the next inspection. The records sampled contained risk assessments, and the inspectors saw evidence that clients signed behavioural agreements on admission. Samples of these were available in the client handbook. The complaint investigation undertaken as part of this Inspection highlighted that Life Works Community Limited did not risk assess one-to-one sessions between clients and counsellors. Life Work’s must risk assess these sessions to ensure that clients and staff are safeguarded. In order to minimise risk, and because of the nature of the client group, Life Works has a list of items that clients are not allowed to have in their bedrooms or during their stay. These lists are detailed in the client handbook. Staff spoken to during the Inspection were aware of and were always conscious of client confidentiality. Staff and clients sign an agreement with regard to maintaining confidentiality of client records and information shared in group sessions. This is detailed in policies within both the client handbook and staff handbook. The Inspectors also saw that clients completed a list of those relatives and friends with whom Life Works Community could share information. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 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) 15 and 16 Policies and programmes are in place to support clients to maintain appropriate relationships with friends and family. Client roles and responsibilities and daily activities are defined as is appropriate for clients receiving this kind of treatment. EVIDENCE: One client spoken to during the inspection stated that the clients were very supportive of each other. It was detailed in the statement of purpose that family and friends are able to visit on Sundays after the first week of treatment, and a family week is arranged as part of the treatment programme, in which family and friends can join in treatment sessions for example, Pilates. One client stated that access to community groups is dependent upon a clinical assessment of your needs at the time. The client stated that this was acceptable. The Manager advised the Inspectors that a set weekly programme is in place for all clients, as was detailed in the statement of purpose. A client spoken to Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 13 during the Inspection confirmed that they did not have any option over their daily routine. The client clearly stated that they did not want choice over their daily routine at that time, and the timetable they currently had met their needs. The Inspectors recognise that guidance from the European Association for the Treatment of Addiction states that treatment programmes will require that clients participate fully in all treatment activities. The client responsibilities with regard to personal and communal space and housekeeping are clearly detailed in the statement of purpose. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 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) none of these standards were assessed at this inspection. EVIDENCE: Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 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 & 23 Although complaints had been responded to promptly, timescales for response and all information relating to complaints must be available. Life Works had not to date followed Surrey’s Multi Agency Protection of Vulnerable Adults Procedures. EVIDENCE: This inspection was undertaken as part of a complaint investigation. A complaint procedure was available and a client spoken to confirmed that they knew who they could raise concerns with and would be happy to do so. Although the client did clearly state that at the time of the inspection they had no concerns. This procedure must also include timescales for response to complaints. The Manager had a log of all complaints received since the last Inspection, and it was observed from copies of letters with regard to these complaints, and the complaint form that the initial complaints had been responded to within 5 working days. However, it was observed that in some cases letters referred to had not been included in the complaints log. All records in relation to a complaint must be held. The Manager confirmed that training in the protection of vulnerable adults had been completed by most of the staff team prior to the inspection, and that a second training session had been arranged. Life Works Community Limited must ensure that all staff, ancillary staff, and clinical staff have completed this training. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 16 Life Works Community Limited had not followed Protection of Vulnerable Adults Procedures appropriately following a recent incident of theft, and this had been resolved internally prior to notifying the police. The Inspectors also found that the investigation in relation to a recent complaint received by the CSCI Surrey Local Office, should have been referred for investigation under the Surrey Multi-Agency Protection of Vulnerable Adults Procedures and had not been. Therefore Life Works must ensure that their staff are aware of these procedures and follow them in all incidents that involve vulnerable adults and that under no circumstances should an internal investigation be completed unless directed to do so. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 17 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) none of these standards were assessed at this inspection. EVIDENCE: Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 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) 34, 35, and 36 Personnel files had improved, however not all references held had been requested directly by Life Works. EVIDENCE: The Manager provided CSCI Surrey Local Office with a copy of a signature sheet completed by members of staff as they received copies of the General Social Care Council Code of Conduct. Four staff files were sampled during the inspection. At least two references were held on these files. One member of staff had been recruited from outside of the UK, and had collected a number of references and letters that verified their qualifications, themselves. It was not evident that Life Works Community Limited had checked these. All references must be requested by Life works Community Limited and all written requests must be made on Life Works headed paper. Life Works would be advised to verify verbally all written references, and to keep a record of when this has been done. All personnel files sampled contained an original copy of an enhanced CRB check. These checks must be held in a separate and secure location, and destroyed once checked by a CSCI Inspector. The Inspectors observed that staff had signed contracts on file. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 19 The Manager provided the Inspectors with copies of supervision records that evidenced that these had been completed regularly. The Manager also provided the Inspectors with evidence that members of staff had received their appraisals in February 2005. IT was not clear that all staff had received mandatory training, however, at the time of the inspection the Manager stated that that they were in the process of reviewing staff training needs, in order to develop a detailed training programme, this must be completed. This will be inspected in more detail at the next inspection. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 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) 39, 41 Record keeping had improved, but further improvements must be made. Clients should be encouraged to give feedback in order to ensure that their views can underpin the new quality assurance programme. EVIDENCE: The Manager showed the Inspectors a detailed quality assurance programme that they were in the process of introducing. This would involve identified staff reviewing how well the service was performing against The National Minimum Standards for Younger Adults. Exit questionnaires were also observed on client files, however some had not been completed. Life Works would be advised to encourage clients to use these at the end of their treatment. The Inspectors observed that the detail of care records had improved gradually since the last Inspection. However staff advised the Inspectors that there was a range of documents held with regard to client care. The Inspectors did not observe the records kept by the clinical team. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 21 It was not evident that detailed notes of all one-to-one client/counsellor sessions had been kept. Life Works strongly advised to keep these records. Please also see comments under standard 6. Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 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 2 3 x x 3 Standard No 22 23 ENVIRONMENT Score 2 1 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 x x 2 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score x x x x x x x Standard No 11 12 13 14 15 16 17 x x x x 3 3 x Standard No 31 32 33 34 35 36 Score x x x 2 2 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Lifeworks Community Ltd Score x x x x Standard No 37 38 39 40 41 42 43 Score x x 3 x 3 x x H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 23 No 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. 2. Standard 1 6 Regulation 4 15 Requirement The statement of purpose must be reviewed and updated. Life works must ensure that individual care plans are developed and where appropriate are agreed with the client. These plans must reflect the information detailed under standards 2 and 6 of the National Minimum Standards for Younger Adults. Typed records must be printed, signed and dated, as they are completed. Life Work’s must risk assess oneto-one sessions to ensure that client’s and staff are safeguarded. The complaint procedure must include timescales for response to complaints. All records in relation to a complaint must be held. Life Works must ensure that their staff are aware of the Surrey Multi-Agency Protection of Vulnerable Adults Procedures and follow them in all incidents that involve vulnerable adults and that under no circumstances should an internal investigation Timescale for action 26 June 2005 26 June 2005 3. 4. 6 9 17 12 (1) (a) 26 May 2005 26 May 2005 26 May 2005 26 May 2005 26 April 2005 5. 6. 7. 22 22 23 22 22 13 (6) Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 24 8. 34 17 9. 34 17, 19 10. 35 18 (1) (c) be completed unless directed to do so. CRB checks must be held in a separate and secure location, and destroyed once checked by a CSCI Inspector. All references must be requested by Life works Community Limited and all written requests must be made on Life Works headed paper. The staff training programme must be completed. 26 April 2005 26 April 2005 26 July 2005 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. 3. Refer to Standard 6 6 34 Good Practice Recommendations Life Works would be advised to use a standard template and continual care recording for clarity and continuity of information. Life Works would be advised to review the number of care records held by different members of staff and must ensure that all records are held on the client’s file. Life Works would be advised to verify verbally all written references, especially those that may have been supplied by the employee themselves, and to keep a record of when this has been done. Life Works would be advised to encourage clients to use these at the end of their treatment. Life Works are strongly advised to keep detailed records of one-to-one sessions. 4. 5. 39 41 Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection The Wharf Abbey Mill Eashing Surrey GU7 2QN National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Lifeworks Community Ltd H58 S59060 Life Works V224097 260405 Stage 4.doc Version 1.30 Page 26 - 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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