Inspection on 19/04/05 for Pathways North West Ltd

This inspection was carried out on 19th April 2005.

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

Other inspections for this house

Pathways North West Ltd 11/04/07

Pathways North West Ltd 06/12/05

Pathways North West Ltd 04/11/04

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

CARE HOME ADULTS 18-65 Pathways North West Ltd 136 Whalley Road Accrington Lancashire BB5 1BS Lead Inspector Lynn Mitton Unannounced 19 April 2005 10:00 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. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Pathways North West Ltd Address 136 Whalley Road Accrington Lancashire BB5 1BS 01254 236411 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) clmason77@aol.co.uk Pathways North West Ltd Miss Claire Mason Care Home only (PC) 5 Category(ies) of Mental disorder, excluding learning disabilities or registration, with number dementia (MD) 5 of places Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1 The service must, at all times, employ a suitably qualified and experienced manager who is registered with the Commission. Date of last inspection 04 November 2004 Brief Description of the Service: Pathways Northwest Limited is registered with the Commission for Social Care Inspection to provide personal care and accommodation to 5 adults with mental health problems.The premises are a spacious mid-terraced garden fronted property that is situated in a residential area of Accrington. The home is within walking distance to the town centre of Accrington and is close to local amenities including a post office and bus stop.Accommodation is provided in 5 single bedrooms. Shared space is 2 lounges dining room and a kitchen.The home aims to provide structured rehabilitative support that responds to the needs of service users to help them achieve their maximum potential.There are a range of therapeutic activities i.e. stress management and problem solving available. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 6 hours. A partial tour of the premises took place. Two of the staff on duty plus the registered manager were spoken to, and four of the resident’s also contributed to the inspection process. One resident was on holiday in the Lake District at the time of the inspection, and three resident’s have a holiday to North Wales planned in May. What the service does well: What has improved since the last inspection? What they could do better: Prospective residents must have their needs assessed by the home prior to their admission to the home. This will ensure that staff are sure they can meet their needs. Resident’s contracts must be fully completed. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 6 The registered person must visit the home, as he is required to do by the legislation. He must also complete a report following each visit. 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. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.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 Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.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) 2 and 5 Improvements to the assessment process prior to admission to the home would ensure that the home could confirm its ability to meet the resident’s needs. There were shortfalls in the completion of resident’s contracts. EVIDENCE: There had been no new admissions to the home since the last inspection. Therefore, no further action had been taken regarding assessing potential new residents needs since the last inspection. The inspector saw two residents’ contracts. These were detailed documents. Both had been signed and dated by the residents, but did not say what the cost of the placement was. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 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 standard(s) 6, 7 & 9. Improvements to the care plan format enabled residents involvement in goal setting and care planning. These must be implemented for all residents. Policies and practices enabled residents to make decisions about their lives. The risk assessment and management framework supported residents to take responsible risks. EVIDENCE: New person centred plans and health check documentation were being introduced. These were detailed documents. The plans included residents’ own perceptions of their strength needs and goals. Records showed that plans were reviewed by the resident, their family, and any professionals involved in their care. The care plan and health checks must be fully implemented. Residents talked to the inspector, and observations were made, demonstrating a number of ways in which they made decisions about their daily lives. For example, one resident said that there was “plenty going on” and that they “got out and about a lot”. The policy of the home was to promote responsible risk taking and freedom of choice. Individual plans contained risk assessments and management strategies. These were agreed by the residents, who advised the inspector they Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 10 understood the reasons for any strategies in place. For example one resident told the inspector that staff would not enter any bedroom unless staff felt there was a risk to the resident’s wellbeing. The resident felt this was reasonable and acceptable. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 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 standard(s) 16 & 17 Resident’s privacy was respected and they were valued as individuals. They were each given opportunities to maintain their independence. Individual dietary needs were catered for. Residents were encouraged to participate in shopping, planning and preparation of meals. EVIDENCE: Residents said that they felt their rights and wishes were respected and gave examples of how and when this had occurred (see previous standards). There was still no reference to residents preferred form of address on their care plan. The inspector saw two residents making their own lunch. A record of what each resident eats was kept. Each resident made their own meals with staff support as required, except tea which was a communal meal. Halal meats were provided for one resident. Residents were advised individually about nutritionally balanced diets. The 4 weekly menus were discussed during residents meetings and reviewed approximately every 4 months. Residents were given a weekly budget to buy their own food at lunchtime. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 12 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) 18 & 20 Personal support was offered in accordance with resident’s wishes, and in a way that promoted privacy dignity and independence. Policies and practices for managing and administering medication were in good order. EVIDENCE: Residents advised the inspector that they receive personal support in the way they prefer and require, and gave the inspector instances of when this had occurred. One resident told the inspector about the “brilliant” relationship he had with his key-worker and how he valued this relationship and support. The inspector also noted instances of good practice during the inspection. One resident told the inspector “I can’t fault it” referring to the care he received. Individual plans identified residents personal support needs. On the day of the inspection 4 staff members received Boots monitored dosage system training. All staff have now received this training. Further medication training for staff was being pursued. Policies and practices for managing and administering medication were in place. One resident was self-medicating. A risk assessment had been completed in this regard. All recommendations except one good practice issue had been implemented since the Commissions pharmacist visited in January 2005. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 13 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 There was a clear complaints procedure and evidence that resident’s views were sought and acted upon. Staff spoken to had a good understanding of adult protection issues, ensuring that any allegations would be dealt with appropriately. Two outstanding recommendations had been mostly attended to. EVIDENCE: One resident gave the inspector an example of when he had raised concerns about a member of staff with the manager and how this had been dealt with to his satisfaction. Another said that if he had any worries he felt very comfortable talking to staff about them. The Commission had received no formal complaints. Policies and practices regarding concerns complaints and protection were in place. Details of the Commission had been updated. The homes policy regarding the “Management of resident’s monies and financial affairs” still needed reference to staff not involving themselves in the financial affairs of residents’. Resident’s meetings were held monthly and minutes kept, and included an opportunity for resident’s to raise any concerns. Two staff spoken to by the inspector knew what to do should they have any concerns about resident’s wellbeing. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 & 30 The standard of décor and furnishings provided a comfortable and homely environment for residents. The standard of cleanliness and hygiene was good. EVIDENCE: The home was clean and tidy, and there were no offensive odours. The home was newly registered with the Commission in June 2004 and had been fully re-furbished prior to this. A monthly check list was completed to ensure the standard and safety of the building. A staff member who had trained in safe working practices did this. Residents told the inspector that staff do not enter their bedrooms unless they have concerns for their safety and wellbeing, and that they (the residents) were in agreement with this. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 15 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) 32 & 35 Staff spoken to and observed by the inspector demonstrated a good understanding of the needs of the residents. There were sufficient staff numbers on duty to meet the resident’s needs. Staff should complete their NVQ training. EVIDENCE: The staff team had been divided into two specific teams for each Pathways establishment since the last inspection. There were no staff vacancies at the time of the inspection. Staff training was ongoing and relevant to the resident’s living at Whalley Road; for example, the district nurse had trained all care staff with regards to one resident’s medication needs. The inspector observed resident’s being supported by competent staff. According to the rota, there were at least three staff members on duty from 9am – 5pm and two staff meetings from 5 – 10pm, during the night there was one wake and watch and one sleep-in person on duty. There was always a nominated senior staff member on duty or on call. Of the 12 care staff, 4 had completed NVQ 2/3 training, a further 3 were undertaking this training. A training matrix was in place. One resident said that he felt very comfortable talking to staff. Another resident said that he thought the management was very efficient. Each staff member had one area of responsibility (an allocated task) for example, COSHH, Menu’s, 1st Aid provisions. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 16 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) 40, 42 & 43 The registered person had not undertaken any Regulation 26 reports. The Commission has written to the registered person about this. Other outstanding requirements and a recommendation had been met since the last inspection. The home was run to ensure the safety and welfare of residents and staff were safeguarded. General good practice was in place with regard to the safety and welfare of the staff and residents. EVIDENCE: The Commission had received no Regulation 26 reports, which the registered person must comply with. There were policy and procedure’s in accordance with Appendix 3 in place. There was evidence that relevant policy and procedures were brought to the attention of residents at residents meetings. It was established that there were no hot water storage tanks at Whalley Road, so the outstanding requirement from the previous inspection report was no longer applicable. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 17 All staff (except 2 bank staff) had completed food hygiene and ½ day 1st Aid training. Hot water temperatures were checked and recorded weekly. Fridge and freezer temperatures were checked and recorded daily. Fire evacuation drills were completed monthly, and fire alarm tests were completed weekly. Staff spoken to knew the fire procedure. There was a good practice procedure in place where the home was routinely checked for fire hazards, e.g. congested areas and smoking rules being adhered to. The inspector was advised that the registered manager and deputy were due to become supernumerary to the staff rota in order to spend more time with resident’s, staff and administrative tasks. They were aware that they must still be able to demonstrate hours they worked at the home. Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 18 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 x 1 x x 2 Standard No 22 23 ENVIRONMENT Score 3 2 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 3 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 x x x x x 3 Standard No 11 12 13 14 15 16 17 x x x x x 2 3 Standard No 31 32 33 34 35 36 Score x x x x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pathways North West Ltd Score 3 x 2 x Standard No 37 38 39 40 41 42 43 Score x x x 3 x 3 2 v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 19 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 YA2 Regulation 14(1) Requirement Assessments by the funding authority and the service provider must be completed for all service users. This requirement remains outstanding from the inspection of November 2004. Contracts must be fully completed and signed by the registered person and service user, and a copy kept on file. This requirement remains outstanding from the inspection of November 2004. Care plans must be fully implemented for all residents Service users preferred form of address must be included in the plan of care. This requirement remains outstanding from the inspection of November 2004. The registed person must visit the home at least once a month and prepare a written report on the conduct of the home. The registered person shall supply a copy of this report to the commission and the registered manager. This requirement remains outstanding from the inspection of November 2004. Timescale for action 1st June 2005 2. YA5 5 (1b&c) 1st June 2005 3. 4. YA6 YA16 15(1) 12 1st June 2005 1st June 2005 5. YA43 26 19th April 2005 Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 20 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 YA20 YA23 YA32 Good Practice Recommendations Medication training should be completed by all staff administering medication to residents. Policies and procedures should include reference precluding staff involvement in making or benefiting from residents wills (23.6) 50 of care staff should achieve NVQ 2 by 2005 Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 21 Commission for Social Care Inspection 1st Floor, Unit 4 Petre Road, Clayton-Le-Moors Accrington Lancashire. BB5 5JB 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 Pathways North West Ltd v222076 f57 f07 s59734 pathways (whalley road) v222076 april 19th 2005 stage 2.doc Version 1.30 Page 22 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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