Inspection on 06/12/05 for Pathways North West Ltd

This inspection was carried out on 6th December 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 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 1 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 19/04/05

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 Mrs Lynn Mitton Unannounced Inspection 6th December 2005 09:30 Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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 Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Pathways North West Ltd Address 136 Whalley Road Accrington Lancashire BB5 1BS 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) Pathways North West Ltd Miss Claire Mason Care Home 5 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (5) of places Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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 19th April 2005 Date of last inspection 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 DS0000059734.V264650.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection was unannounced and took place over 4 hours. A partial tour of the premises took place. The registered manager and deputy were spoken to, 3 service users were also spoken to, and interaction between staff and service users was observed, Throughout the report there are various references to the “tracking process”, this is a method whereby the inspector focuses on a small representative group of staff member and service users. Records pertaining to these people were inspected. Policies and practices were also looked at. There were 4 service users living at Whalley Road at the time of the inspection. What the service does well: What has improved since the last inspection? Comprehensive assessment documents were now in place to ensure that any prospective new service user would have their needs identified accurately and from this it could be decided if Whalley Road could meet these needs. Service users contracts were now in place, giving clear and concise details about the service and facilities that are on offer. Service users preferred name was now included on the care plan documents. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 Page 6 The registered person was conducting a monthly report about the home most months. However these should be completed and a copy sent to the Commission every month. 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. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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 Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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): YA2 & YA5 Needs assessments were in place identifying the care needs of service users so that support staff would have a clear understanding of how they needed to support them. Contracts explained what service users could expect, and what was expected of them in order for them to live at Whalley Road. EVIDENCE: There had been no new admissions to the home since the last inspection. The inspector noted that new assessment and social functioning forms had been developed, these were seen by the inspector and were considered to be suitable documents to ascertain service users needs prior to admission. Service users contracts were seen. These had been signed and dated by the service user, and fully explained the terms and conditions of their residence at Whalley Road. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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): YA6 Information on care and health plans meant that service users’ needs were known to support staff and were being met in a consistent way. EVIDENCE: Two service users care plan were examined. These recently developed and implemented documents contained detailed information about the level of support needed for staff to ensure continuity of care. They had both been recently reviewed. The inspector felt these documents included excellent content and detail and included service users input. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 Page 10 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): YA12, YA13, YA15 The home was run to make sure the service users had opportunities to enjoy their life and to fulfil their potential. Service users had regular access to their local community, and had opportunities to maintain family links. EVIDENCE: Each service user had an individual activity programme, which included community-based activities. The inspector was satisfied that these were based on meaningful and valued activities, regularly accessing their local community. These also endeavoured to ensure service users had opportunities to fulfil their potential socially, emotionally, and maintain their independent living skills. The registered manager and inspector discussed the difficulties of motivation for some service users. A weekly plan record gave service users an opportunity to write about what they had done each day, how they felt about doing these things and any other issues (for example monies) that may have had an impact on their enjoyment. Activities included voluntary work and household tasks. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 Page 11 Most service users have regular contact with their families. The inspector was satisfied that service users families were encouraged to be involved in the care planning for each service user. Service users preferred name was now included on the care plan documents. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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 the following standard(s): YA19 The health needs of service users case tracked had been identified and, how they would be met, recorded. EVIDENCE: There was evidence that service users mental health and physical health needs were being given due care and attention. Both service users case tracked had a “Staying Well Plan” and a health check in place. These were very detailed documents and had been recently reviewed. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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 the following standard(s): EVIDENCE: These standards had been examined and met at the last inspection. There had been no complaints since the last inspection. The inspector was advised there were no adult protection issues at the time of the inspection. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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 the following standard(s): Overall the standard of décor and furnishings provided a comfortable and homely environment for service users. EVIDENCE: These standards had been examined and met at the last inspection. The inspector conducted a tour of the homes communal areas. The inspector was advised that the outside of the home had been re-painted, the kitchen and utility area had also been re-painted, a new cooker had been purchased and new blinds for the bathroom. The Environmental Health Officer had recently visited and given the home a clean bill of health. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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 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): YA34 Staff spoken to and observed by the inspector demonstrated a good understanding of the needs of the service users. There were sufficient staff members on duty to meet service users needs. Staff recruitment records, which would ensure service users were safe, were in place. EVIDENCE: Whalley Road was fully staffed at the time of the inspection. 2 staff members were case tracked. Their files contained information that demonstrated appropriate checks had been taken to ensure that service users were safeguarded. Induction training met TOPSS specification. The inspector was advised that service users were consulted about the recruitment of staff during their probationary period. The inspector and registered manager discussed having regular 1:1 sessions with new staff members during their probationary period. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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 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): YA37, YA39 & YA43 An experienced and appropriately trained manager ran the home. Some monthly visits by the registered person were now taking place, these should be more consistent, be recorded and a copy of the report sent to the Commission. The inspector was satisfied that service users were regularly consulted regarding the running of the home. EVIDENCE: The registered manager had completed her NVQ4 training in 2004, and this year had also completed the registered manager’s award. The inspector was satisfied that there were clear lines of accountability within the home and with the registered person. A business plan was in place and seen by the inspector. The Investors in People award was re-issued to Whalley Road in March 2005. Service users meetings took place each month the next one was due to be held on December 6th. An agenda was seen for this meeting. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 Page 17 The last service users survey took place in November 2004. The inspector advised that this process should be repeated at least on an annual basis. The Commission had received some monthly reports from the registered person, however not every month had been accounted for. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 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 3 X X 3 Standard No 22 23 Score X X ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 4 X X X X Standard No 24 25 26 27 28 29 30 STAFFING Score X X X X X X X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 Standard No 31 32 33 34 35 36 Score X X X 2 X X CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Pathways North West Ltd Score X 4 X X Standard No 37 38 39 40 41 42 43 Score 3 X 2 X X X 2 DS0000059734.V264650.R01.S.doc Version 5.0 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 YA43 Regulation 26 Requirement The registered 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 31/03/06 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. 4. 5. Refer to Standard YA20 YA23 YA32 YA34 YA39 Good Practice Recommendations All staff administering medication to residents should complete medication training. 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 New staff members should receive monthly 1:1 support during their probation period. An internal audit should take place at least annually. Pathways North West Ltd DS0000059734.V264650.R01.S.doc Version 5.0 Page 20 Commission for Social Care Inspection East Lancashire Area Office 1st Floor, Unit 4 Petre Road Clayton Business Park Accrington 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 DS0000059734.V264650.R01.S.doc Version 5.0 Page 21 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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