CARE HOME ADULTS 18-65
Lifeways Queens Drive 95 Queens Drive Newton-le-Willows St Helens Merseyside WA12 0LP Lead Inspector
Mr John Mullen Key Unannounced Inspection 5th October 2006 09:00 Lifeways Queens Drive DS0000064129.V314100.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 Lifeways Queens Drive DS0000064129.V314100.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. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION
Name of service Lifeways Queens Drive Address 95 Queens Drive Newton-le-Willows St Helens Merseyside WA12 0LP 02088771338 02088779543 lancashire@lifeways.co.uk b.pritchard@lifeways.co.uk Lifeways Community Care Ltd 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 Amanda Jayne Critchley-Riley Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION
Conditions of registration: 1. The service should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. Service Users to include up to 2 in the category of Learning Disabilities. 6th March 2006 2. Date of last inspection Brief Description of the Service: 95 Queens Drive is a respite home for up to two adults with learning disabilities. It is managed by Lifeways Community Care Ltd and the registered manager is Mrs Amanda Jayne Critchley-Riley. The home was established to partly replace the respite service provided by St Helens Council. 95 Queens Drive is a domestic property with a lounge, a dining room, two single bedrooms for residents and one for staff. The home has one downstairs toilet and one upstairs toilet with shower and a separate utility room. It was registered on 15th September 2005. The home’s charges vary from £50.40 to £74.30 per week according to an assessment of residents’ means. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. This was an unannounced key inspection of 95 Queens Drive which included a site visit. A tour of the premises took place; staff were spoken to and care records inspected. Interviews were held with the registered manager and two care workers. Three residents were seen and three families were contacted. What the service does well: What has improved since the last inspection?
Since the last inspection the home has ensured that all residents have full risk assessments in place. In addition, it has adapted some of its documentation to confirm its status as a registered home. The registered manager is providing supervision for staff and there are regular, monthly visits by Lifeways’ managers to ensure that the home is supervised and supported. The registered manager has acquired up to date guidance on medicines to ensure that the home’s practices are in accordance with good practice. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 6 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. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 8 Choice of Home
The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 This judgement has been made using available evidence including a visit to this service. The home has varying information on which to base its work so that it cannot be consistently planned. EVIDENCE: Each of the case files seen had a care needs assessment in them although they varied in format and date meaning that there was an inconsistency of information. Two had reasonably recent assessments but one dated from 1999 and the registered manager confirmed both that this was out of date and that the relative of the resident wanted it reviewed in order to increase the number of respite stays available. The registered manager confirmed some difficulty in getting assessments from the local authority but said they were eventually obtained so that the home has some information on which to base its work. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 9 Individual Needs and Choices
The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7 and 9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Care planning is in place and residents are being cared for appropriately and safely. EVIDENCE: An examination of files showed that the home has started to implement new Lifeways Care Plans so that they more up to date. In two of the files the plans were with relatives for them to complete and sign to show their agreement. One file seen did not have the new version in place and the care plan was out of date with no recent review. An interview with the registered manager revealed that approximately half of the care plans have been updated and these are being done incrementally so that within the near future all residents will have a relevant care plan. Families and staff interviewed were aware of the plans for residents and confirmed that these were in accordance with their needs. Observations on the days of the inspection showed that residents could make choices to the extent that their capabilities allowed. One resident was colouring and drawing, another stated how happy he was to be visiting a local
Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 10 shopping centre and a further visit revealed a resident happy to have made a flower arrangement. Contact with families showed that they were particularly pleased with the increased activities available based on individual choices and preferences. An interview with the registered manager revealed that approximately one third of residents can be given money to spend and interviews with staff showed they are encouraged to do so. The home has house meetings and the minutes of these showed that there was good involvement of residents and they were actively encouraged to express their views on relevant matters. An examination of files confirmed that full, current risk assessments are in place so that residents can be cared for safely. The home accommodates residents with a lower level of disability which means that risks are accordingly lower but appropriate action has been taken where necessary, including fitting extra security on the front door because of the risk associated with one specific resident. Interviews with staff and families showed that residents were being cared for safely and appropriately. Family member comments included that their relative “loves going there” and that a daughter “really enjoys the experience”. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 11 Lifestyle
The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 13, 15, 16 and 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home cares for residents in a manner that promotes individual preferences, promotes community links and provides nourishing diets so that residents are correctly cared for. EVIDENCE: Interviews with the registered manager confirmed that the home uses a wide variety of community activities including trips to garden centres, cinemas, discos and Knowsley Safari Park so that they are pleasantly occupied. A visit to the home at the weekend showed that a staff member was taking residents out on both days on trips in accordance with their wishes. Residents expressed satisfaction with this and families contacted were particularly pleased with the external activities available. Those whose relatives stayed in the previous placement favourably compared 95 Queens Drive to it, but particularly in the area of activities. As a respite home, families do not tend to visit as often but rather telephone the home. Families contacted had been to the home and were very
Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 12 complimentary about it. Comments included “nothing but praise for the home” and one mother, whose son had attended for the first time, said that her son was “ very pleased” with the experience and said she was reassured by the care he received. All families said that the home kept in touch very regularly with them and the registered manager occasionally visits so that contact is maintained. An interview with the registered manager, other staff and observations on the day revealed a relaxed, uninstitutional approach to care resulting in a homely atmosphere. Residents are not restricted and there are few rules, resulting in a happy environment. Residents do not have keys to their bedrooms, which is their wish, but this is not written down in their files showing that this is an individual choice. The home keeps three-week menus which are interpreted flexibly depending on individual choices. In addition, the home records what residents have eaten so that their diet is checked. Residents said they were happy with the food on offer and this was confirmed by families. New residents are visited by the registered manager who lists their food likes and dislikes so that the home can cater for their preferences. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support
The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home cares for residents in a manner that promotes good practice, including in the area of medication, so that families can have confidence in the service. EVIDENCE: Observations on the day of the inspection found that personal support was being given appropriately, meaning that residents were being supported in a correct manner. The home is arranging for two male workers to do shadowing of care so that they can be used when necessary. This means that although at present there is only female staff, this can be changed to meet individual need. The home has flexible rules for rising and going to bed so that there is no institutional approach to care. The registered manager does not use a key worker system because of the nature of the care and the small number of staff but is promoting consistency of staff through a permanent workforce. At present two staff are covering temporarily whilst one member of staff’s appointment is completed but these staff are regularly used so that consistency of care is promoted. As a respite home 95 Queens Drive accesses health care as necessary. Interviews with staff and families revealed no problems with this.
Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 14 The home has now acquired full guidelines on the correct administration of medicines in homes to underpin its practice. All medication records seen in files were correct to confirm the correct administration of medicines. The residents being accommodated at the time of the inspection were not taking medication but other records showed proper recording. The registered manager confirmed that all staff had received medication training and that correct procedures were in place so that no problems in this area were identified. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 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 the following standard(s): 22 and 23 Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home has correct procedures to protect residents although recording and training needs to be improved to meet best practice. EVIDENCE: An examination of the complaints’ procedure confirmed that the name and address and telephone number of the Commission was contained therein so that full information is available to residents and families. An examination of the book detailing complaints showed there were three complaints which had been thoroughly investigated but the dating was either not exact or incorrect which needs attention to ensure accuracy in this area. Contact with families and residents revealed no complaints about the service but rather a very positive view of 95 Queens Drive. The home has St Helens Council’s adult protection procedures to ensure a consistent and thorough approach in this area. All staff have had police checks and this was confirmed by the staff files which showed that staff are not being recruited unless this is undertaken. Not all staff have had training in the prevention of abuse to ensure that they are up to date in this subject. There has been no allegation of abuse since this home opened but staff need to be aware of the procedures to be followed to ensure the safety of residents. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 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 the following standard(s): 24 and 30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home is fully suitable for its purpose being homely, comfortable and pleasant in appearance. EVIDENCE: A tour of the premises found it of a very good standard being furnished, decorated and maintained to a high standard. Residents spoken to were happy with the premises as were their family members, all of whom had visited the home. One relative described the house as “very nice” and another as “homely”. The home is domestic in character and fully fits into the local environment which also was commented on by relatives who felt that the smallness of the property was an advantage compared to previous placements. The home was clean throughout and has appropriate facilities to maintain these standards. The washing machine is appropriately sited so that the laundry is correctly managed. The home only has one resident who is incontinent and, therefore, this does not present as a problem and this was confirmed by the inspection which found the home hygienic throughout. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 17 Staffing
The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 34 and 35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Staff are being appointed correctly and trained to a good standard although this needs to be better planned so that training needs are readily identified. EVIDENCE: The main staff files are not contained within the home but kept centrally although the manager in interview said she was confident that the recruitment process was thorough and appropriate. An examination of staff files confirmed that police checks have been taken and this was confirmed in interviews, confirming that staff are not being appointed inappropriately. The registered manager confirmed that staff are given the required information upon appointment and no problem in the recruitment process was revealed. Interviews with the registered manager and documents seen confirmed there had been an increase in the training available to staff. This includes a full induction programme and core training which includes health and safety issues as well as other topics. The home has not produced a full training and development plan to ensure that training is planned systematically. Staff seen during the inspection were temporarily working in the home whilst staff are being appointed but they seemed well suited to their work and had regularly worked at 95 Queens Drive so they were familiar with the residents and the procedures. Families contacted had a very high opinion of staff in the home.
Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 18 One said that staff were “very, very good”, especially the registered manager and another said he had “nothing but praise for the home”. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home
The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39 and 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, based on residents’ needs and is a safe environment so that it represents a good facility for the care of residents. EVIDENCE: There has been no change in registered manager and she is expected to complete her management qualification in April 2007 which will mean she will have taken all the necessary qualifications. Interviews with the registered manager confirmed that she is fully committed to her work and has made significant improvements to the home so that it continues to develop. Interviews with staff and families confirmed a very high opinion of her competence and leadership. The home has a quality assurance satisfaction survey taken every six months to gauge family views. The registered manager said this is to be changed to make it more relevant and up to date. The home has a detailed and effective external monitoring system on a monthly basis which also acts as a check on
Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 20 progress. However, it does not have an annual development plan and has not fully integrated its quality assurance system so that it is continually developing it service. A tour of the premises found it a safe home for both residents and staff. Insurance, Gas and Legionella certificates were in place, a fire risk assessment from January 2006 and a risk assessment of the premises from November 2005, so that the safety of residents is promoted. A Fire Certificate of Inspection was undertaken on the 10th October which revealed that further aids to safety are required and the registered manager is in the process of implementing these. Training records show that staff are being trained in health and safety matters as part of their induction process and this needs to be integrated into a training plan so that this is kept under review. Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 21 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 2 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 2 23 3 ENVIRONMENT Standard No Score 24 4 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 X 33 X 34 3 35 2 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 N/A 13 3 14 X 15 3 16 2 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 2 X X 3 X Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? YES 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 YA6 Regulation 15 Requirement The registered manager to ensure that residents’ plans are reviewed at least six-monthly. (Previous timescale of 1st June 2006 not met). The registered provider to ensure that there is a training and development plan for the care home. The registered manager to ensure that an up to date care needs assessment is kept on residents. The registered manager to ensure that it is recorded when residents are deemed not capable of having a key. The registered manager to ensure that complaints are dated properly. The registered provider to develop a full quality assurance system. Timescale for action 01/04/07 2. YA35 18 01/12/06 3. YA2 14 01/04/07 4. YA16 12 01/12/06 5. 6. YA22 YA39 22 24 01/12/06 01/10/07 Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Lifeways Queens Drive DS0000064129.V314100.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Knowsley Local Office 2nd Floor, South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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