Inspection on 06/03/06 for Lifeways

This inspection was carried out on 6th March 2006.

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 no outstanding requirements from the previous inspection report, but made 6 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Lifeways 28/06/07

Lifeways 05/10/06

Similar services:

Clover House

Parkside

Park Lodge

Mere Hall View

St Bonaventures

Hudson Road

Whitewalls

Home Farm

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

CARE HOME ADULTS 18-65 Lifeways Queens Drive 95 Queens Drive Newton-le-Willows St Helens Merseyside WA12 0LP Lead Inspector Mr John Mullen Announced Inspection 6th March 2006 09:30 Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 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.V277526.R01.S.doc Version 5.1 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.V277526.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Lifeways Queens Drive Address 95 Queens Drive Newton-le-Willows St Helens Merseyside WA12 0LP 02088771338 02088779543 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) Lifeways Community Care Ltd Care Home 2 Category(ies) of Learning disability (2) registration, with number of places Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 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. Date of last inspection Not applicable first inspection. Brief Description of the Service: 95 Queens Drive is a respite care home for up to two adults with learning disabilities. It is managed by Lifeways Community Care Ltd and the manager is Mrs Amanda Jayne Critchley-Riley whose application for registration is near completion. The care home was established to 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 care home has one downstairs toilet and one upstairs toilet with shower and a separate utility room. It was registered on 15th September 2005. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was the first announced inspection of this care home which was registered on 15th September 2005. A selection of the core National Minimum Standards were assessed. The inspection took place over two days and comprised of interviews with the manager, the senior support worker and two residents. Three families were contacted. A tour of the premises took place and a large amount of documents held by the care home were seen. What the service does well: What has improved since the last inspection? What they could do better: Plans on residents exist but need to be reviewed regularly to ensure that they are still fully relevant. Risk assessments must be taken on all residents so that their safety is assured. The care home has full policies to protect residents but Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 6 this would be further enhanced by adapting the Whistle Blowing Policy so that staff can refer to the Commission if necessary. Good training opportunities are available for staff but this needs to be formalised in a training and development plan to ensure that all training needs are fulfilled. Formal staff supervision needs to be fully implemented and regular visits to the home by a senior member of staff undertaken so that all staff are supported. 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.V277526.R01.S.doc Version 5.1 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.V277526.R01.S.doc Version 5.1 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 Care needs assessments are being provided to enable work to be planned appropriately. EVIDENCE: An examination of a selection of files found that each contained a care needs assessment provided by the local authority. Those residents previously accommodated in Duncan Street have had a new assessment undertaken during the transition period but those residents new to the service also had a full assessment of need provided by care management so that full information is available to staff on each service user. Interviews with staff showed them very familiar with the needs of residents which is particularly commendable given that the service has only recently begun. Contact with family members showed that they were very happy with the manner in which their relatives were being cared for and their needs being met. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 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 and 9 Care plans are in place but need to be reviewed regularly to ensure that they are up to date. Risk assessments need to be completed to minimise the possibility of hazards in the care practices. EVIDENCE: An examination of a selection of files held in the care home found an individual plan in each detailing the work to be undertaken with each service user. Most of the plans were social services’ plans but one was a new format, devised by Lifeways, which is also detailed and of a good standard. All the plans seen had been signed by the service user or their parents which is good practice as it shows their agreement with the plans. The plans are not being reviewed at six-monthly intervals which is required to show that they are up to date and have been adjusted to meet changing circumstances. Interviews with staff found them familiar with the work to be undertaken with individual residents and residents seen were happy with the care they were receiving. An examination of files held in the care home showed that some, but not all, had risk assessments in them. The residents residing in Queens Drive tend not to have moving and handling issues because of their relatively low level of disability but, where that was the case, this was recorded on the risk Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 10 assessments. Risk assessments were lacking on new cases referred to the service which must be rectified because residents need to be assessed in order that care is given safely. Discussions with staff, residents and family members revealed no concerns about the risks in the care practices of the care home and showed that staff were acting responsibly in all these matters. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 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 and 17 The care home helps residents integrate into the wider community so that they have an interesting experience during their stay. Family links are actively promoted so that families feel involved with the care home. A good standard of food ensures that residents enjoy their meals in the care home. EVIDENCE: Interviews with the manager and senior support worker showed that the care home is using local amenities including pubs, shops and a disco to integrate residents into the wider community. The care home, according to the manager, has good neighbourly relationships and no problems have been reported so that residents felt at home in the wider community. This will have been helped by the way the property blends into its neighbourhood. The care home does use local transport to take residents out so that, again, the residents have the experience of everyday life. Conversations with two residents showed that they were very happy with their activities inside and outside the care home and families contacted commented on how much more their family members went out of the care home than in their previous placements, so that they were very active and occupied during their stays in Queens Drive. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 12 Although Queens Drive, as a respite facility, would expect to have less links with families, in fact this is not necessarily the case. The manager has sent a questionnaire to all families about their view on the performance of the care home and she telephones family members regularly to keep them in touch with developments. At the time of the inspection one mother was bringing her daughter to the care home and she felt she was very involved with the work of the care home. Other family members contacted by telephone were of the same opinion so that family members, who described the care home as “brilliant” and “top class”, confirmed that contact is constant so that they are reassured and kept informed about their relatives’ stays. The care home records menus and food eaten by residents so that a full record is kept of food consumed. Residents are encouraged to shop if they wish and to help in the preparation of meals to the extent that their abilities and wishes allow. Residents seen were happy with the food on offer and with the mealtimes generally. The manager confirmed that special diets are catered for and that residents are supported to assist with meals wherever possible so that meals and mealtimes are an enjoyable and relaxed experience. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 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): 20 Medicines are being correctly administered in the care home so that the safety of residents is assured. EVIDENCE: An examination of medication sheets being kept in the care home showed that they were being properly completed. A tour of the premises showed that the care home has proper facilities for the storage of medication except in the case of controlled drugs, which no current resident of the care home uses. An interview with the manager showed that she was aware of the extra precautions, including storage facilities, that will be required if controlled drugs are prescribed to ensure that full safeguards are in place. Prior to the inspection there had been an error in medication and this was dealt with properly by the manager so that residents were safeguarded. All staff have had accredited training in the area of medication so that they are competent in this area. The manager did not have the guidelines on best practice and it was recommended to her that she acquires this so that full advice is available to all staff in this area. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23 Complaints are being managed correctly so that residents and families can have confidence in this process. Policies and procedures, including training, has been provided on the prevention of abuse to ensure the safety of residents. EVIDENCE: Lifeways has a full complaints’ procedure which is of a good standard and clearly defines the process. An examination of the book recording complaints showed that they were being dealt with fully and within the timescale required so that they are being properly managed. Lifeways also has a Whistle Blowing Policy which is thorough and appropriate but does not make reference to the care home’s position as a registered care home and the possibility of referral to the Commission. This needs to be rectified so that staff know all avenues available to them if required. Lifeways have ensured that all staff working in the care home have been checked in terms of suitability for the posts and this is recorded in the staff files so that the manager can demonstrate that only suitable people are being appointed. Training records held in the care home showed that staff have been trained in the area of prevention of abuse and the company has full policies on this subject so that staff can be clear about the actions to be taken in the event of an allegation being made. No such allegation has been made since the care home opened and no family had any concern about the safety of their relative in Queens Drive. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24 and 30 95 Queens Drive is a clean, pleasant care home which is fit for its purpose. EVIDENCE: A tour of the premises found Queens Drive to be a pleasant, comfortable care home fit for its purpose. The care home is not designed to accommodate physically disabled residents but is a family-scale home which is well decorated, well carpeted and homely in appearance. Interviews with residents found them very pleased with the standard of accommodation and families contacted felt that this care home was better than the one it replaced, being smaller and more comfortable. A tour of the premises found it clean and hygienic. The care home does not have a sluicing facility but this is not required as the level of incontinence is low and the installation of such a facility would not be appropriate. The care home has full laundry facilities separately sited and appropriate for the size of the care home. Families contacted made comment on the cleanliness of Queens Drive which reinforced their confidence in the care home. This care home does not have separate cleaning staff but an interview with the senior support worker showed that this is easily dealt with as part of the daily routine and this was confirmed by observations on the day. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 16 Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 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): 32, 35 and 36 Staff are well qualified to undertake their role and have been given good initial training although this needs to be planned further to develop staff. Formal supervision of staff is required including visits to the care home from senior personnel so that all are well directed in their work. EVIDENCE: The staff team for Queens Drive consists of a manager, a senior support worker, one permanent support worker and a sessional support worker. The manager is currently undertaking the registered managers award, the senior support worker currently holds a vocational qualification and is currently undertaking a higher level course and the permanent support worker already has a vocational qualification. As a result, the staff group is well qualified professionally to undertake their roles and this has been supplemented by other training opportunities so that staff have remained up to date in their work. Observed interaction between the manager and residents showed that the former relates well to residents of the care home and this was confirmed by interviews with residents who appeared very at ease within the care home. Contact with families showed that they had a high opinion of staff working in the care home and they said they their relatives looked forward to stays within Queens Drive. Interviews with the manager and the senior support worker showed that a large amount of core training has been made available to staff of the care home including medication, epilepsy, prevention of abuse, moving and Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 18 handling and first aid. All the staff have undertaken core training which means that they have been well prepared to undertake their roles. The organisation provides induction training as an element of the core training and staff seen felt they had been well trained in the necessary subjects. This was confirmed by training documents seen during the inspection which confirmed the interviews. The manager does not yet have in place a full training and development plan so that training can be planned and organised for the future and is needed for this purpose. An interview with the manager and documents seen confirmed that formal supervision of staff is to be arranged in the future but is not yet taking place to the extent that is required. Both the manager and the senior support worker felt they were being well supported although there has only been one formal visit to the care home by a senior manager and this is required on a monthly basis to ensure, amongst other matters, that the manager is supported in her work. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 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 and 42 The manager is leading the care home in a positive manner so that it continues to develop. The care home is a safe environment for the care of its residents. EVIDENCE: The manager of the care home has almost completed the registration process which only requires Lifeways to formally accept the Commission’s proposals for this to be completed. She has passed all the elements requiring registration and this should be completed shortly. The manager has not yet acquired the professional qualification required for this post but is in the process of doing so which is acceptable to the Commission. An interview with the manager showed that she has made significant progress in establishing and developing Queens Drive since its registration. This was further shown by the inspection itself and by the comments received from residents and their families who were extremely complimentary about the care home and about her role in it. The care home possesses a file on health and safety matters and this shows that the care home has full policies relating to potentially hazardous substances. It also showed that there is been a lone workers’ risk assessment, Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 20 a fire risk assessment, a risk assessment of the premises, a first aid risk assessment and a food safety assessment all done since registration. As a result, the premises are fit for their purpose. The fire book was being correctly maintained. A tour of the premises found it a safe environment for the care of residents and the security of the premises has been enhanced since registration so that residents are protected against any possible accidents. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 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 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 2 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 X 34 X 35 2 36 2 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 X X 2 X LIFESTYLES Standard No Score 11 X 12 N/A 13 3 14 X 15 3 16 X 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score X X 3 X 2 X X X X 3 X Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 22 N/A 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. 3. Standard YA6 YA9 YA23 Regulation 15 13(4) 22 Requirement The manager to ensure that residents’ plans are reviewed at least six-monthly. The manager to ensure that full risk assessments are taken on all residents prior to admission. The registered provider to adapt the Whistle Blowing Policy to include the name and address of the Commission. The registered provider to ensure that there is a training and development plan for the care home. The manager to ensure that staff are supervised at least six times a year. The registered provider to ensure that monthly visits to the care home are made by an appropriate person. Timescale for action 01/06/06 01/05/06 01/08/06 4. YA35 18 01/12/06 5. 6. YA36 YA36 18(2) 26 01/02/07 01/05/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 Page 23 No. 1. Refer to Standard YA20 Good Practice Recommendations The manager to acquire the Royal Pharmaceutical Society of Great Britain’s guidelines on medicines. Lifeways Queens Drive DS0000064129.V277526.R01.S.doc Version 5.1 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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