Inspection on 19/07/05 for Westover Close, 1c

This inspection was carried out on 19th July 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 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Westover Close, 1c 15/02/07

Westover Close, 1c 12/12/05

Westover Close, 1c 29/11/04

Westover Close, 1c 22/07/04

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Dystlegh Grange

The Good Companions

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Cuerden Grange Rest Home

Cornmill Nursing Home

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Sue Ryder Care Birchley Hall

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

CARE HOME ADULTS 18-65 1c Westover Close 1c Westover Close Maghull Liverpool L31 7BU Lead Inspector Trish Thomas Unannounced 19th July 2005 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. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service 1c Westover Close Address 1c Westover Close Maghull Liverpool L31 7BU 0151 526 4133 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) Parkhaven Trust N/A Care Home 4 Category(ies) of PD - Physical Disability registration, with number of places 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 1. The registered manager to undertake a management qualification (NVQ Level 4 or equivalent ) April 2005 Date of last inspection 29th November 2004 Brief Description of the Service: 1c Westover Close is a purpose built bungalow for four young adults assessed with profound physical disabilities. The home is owned by Parkhaven Trust and there was no registered manager at the time of inspection. Mrs. M. Bridgewater has been recently appointed as manager and will apply for registration with CSCI. The home is well integrated with other domestic dwellings in the street and has a car park at the front of the building and gardens at the side and rear. This is a permanent home, providing twenty-four hour care and support, home cooked meals and laundry services. All those in residence are registered with a local G.P. and therapeutic treatment is provided on the premises by visiting therapists. The home provides a range of moving equipment, and some recent improvements have been made through installation of ceiling tracking to assist in moving residents in comfort and safety. The four residents occupy single bedrooms with adjacent access to a bathroom. Communal space consists of a lounge/dining area and a conservatory. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. Westover Close is purpose-built and provides a relaxed and comfortable environment for the four young people who live there. The manager, Mrs. Bridgewater, is newly appointed and was in the process of getting to know the residents, staff and home’s procedures, at the time of inspection. Mrs. Bridgewater has prioritised taking action to ensure that the home is meeting residents’ needs, and to ensure that staff are supported in their job roles and their training and development needs. There were two residents on the premises at the time of inspection, one was shopping with a member of staff, the other at a hydrotherapy session. The residents observed in the home looked very relaxed and well cared for. The home has undergone a number of staff changes recently, and Mrs. Bridgewater is the fourth manager since the home was opened in 2001. Longterm staff have worked through the changes of manager, providing continuity in direct care to residents. A number of agency staff have been employed in recent months to cover staff vacancies, which have since been covered. There was one part-time care vacancy (of 21 hours per week), which had been advertised at the time of inspection. The conditions of registration referred to in this report apply to the previous manager and will be removed when an updated registration certificate is issued. What the service does well: 1c Westover Close provides a specialist service to young people with profound disabilities and is their permanent home. The home is well integrated into a residential street, with amenities and pleasant walks in the area. The home is purpose-built providing easy access for wheelchairs and a resident who has limited independent mobility. The provider organisation supports staff training and development and has robust recruitment procedures in place. The long-term employed staff have expertise in provision of this service to the four young people in residence. All staff had police clearance and two references on file. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 7 The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 8 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 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 9 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users’ know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 1,2,3,4, and 5. 1c, Westover Close was meeting standards one to five. This is a permanent home to the four young people presently in residence, and regular admissions and discharges are not usual. All residents were referred for this specialist service by Social Services Departments across the country. EVIDENCE: In reading staff files it was evident that the four people in residence had professional assessments. They are all assessed with profound physical disabilities and communication difficulties. Due to their limited capacity to make decisions, there was a high level of input from family representatives and social workers at the time of referral, and there is ongoing communication with families when decisions are made regarding the care and support provided. All residents have been issued with a contract of residence, which was negotiated at the time of admission, with their family advocates. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 10 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate, in all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6,7,9 Shortfalls were noted regarding Standard 6 and 9, the home was meeting standard 7. A new care planning format has been introduced in the last twelve months and much work had been undertaken in transferring information from the previous format. Shortfalls were noted and one requirement and one recommendation are made as follows : Standard 6 Regulation 15 (2) (b) The manager must ensure that care plan reviews are kept up to date. Standard 6.7 The manager should ensure that care plans are maintained in appropriate language. One resident is mobile within the home and he has no concept of danger. The risks he could encounter when moving freely in the home must be fully assessed with regards to the environment, the needs of the other residents, staff activities and his own behaviour patterns. Standard 9 Regulation 13 (4) (a) The manager must ensure that environmental risk assessments are in place with regards to the mobility of one resident and that they are regularly updated. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 11 EVIDENCE: The care plans for all four residents were read. These have been changed to a new format and contained social histories, interests, skills, gifts, communication (means of non-verbal communication documented), routines, preferences, risk assessment, moving and handling assessment. The care plan includes area of need, how it will be met, and who will meet it. There was evidence in the care plans of aid to diet, continence referrals to G.P.s. and paramedical services. Long-term employed staff have developed good communication strategies with the residents over time. Staff approach and interaction with residents at the time of inspection was observed in the lounge, where residents were relaxing. Staff consistently asked residents what they would like to do, or informed them if they were to be moved. Staff comments to residents were not confined to care giving, they initiated conversation and awaited responses. There is ongoing communication between the home and residents’ families and contact is maintained through mutual visits. Care plans were in place for all residents, based on social work assessments, at time of admissions and supported by therapeutic programmes. One resident is mobile, within the home an ongoing environmental risk assessment in relation to his activities, will be a requirement of this inspection. Assessment of need, for all residents, is ongoing on a daily basis. All residents have communication difficulties and the more experienced staff have developed good observational skills, in noting individual reactions and body language to current situations or questions. Due to high levels of disability, O.T. assessments were in place. Specialist equipment is referred to in Standards 19 and 29. Not all care plans were up to date and all should contain at least a monthly review, signed by the key worker. Use of language in care plans was discussed with the manager Mrs. Bridgewater. Examples of two inappropriate terms had been observed in care plans. Mrs. Bridgewater said that some of the staff have requested training in report writing. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 12 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11,17 The home was meeting Standards 11 and 17. There are systems in place in the assessments and care planning processes, in supporting residents to maintain self-esteem and personal relationships. There is always scope to improve residents’ expectations and quality of life in accordance with their changing needs and expectations. Residents’ special dietary needs and meal preferences are on record in the home. EVIDENCE: In discussion with the manager, Mrs. Bridgewater, it was established that all residents have email addresses. They are in regular contact with their families, who do not live locally, through email, mutual visits, holidays and phone calls. A holiday at Centre Parks had been arranged and two of the residents were planning to go, accompanied by four members of staff. Residents preferences and social histories are recorded on their care plans. Residents have been accompanied on recent outings, including, cinema, bowling, hydrotherapy, horse-riding. There is always scope to improve the range of activities and opportunities on offer to residents, in accordance with assessment. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 13 Residents enjoy use of their own videos and music on a daily basis in the home. The lounge provides a comfortable and relaxing environment and staff were offering residents choices of activity, in accordance with their capacity, at the time of inspection. Residents spend time also relaxing in their bedrooms, which are pleasantly decorated and personalised. The residents are assisted to the rear and side gardens in fine weather for barbecues and relaxation. The manager intends to arrange for access from the rear garden to the canal path, a pleasant walk, which residents could enjoy regularly, if access were to be improved for the wheelchairs. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 14 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18, 19 and 20 The home was meeting standards 18, 20. The home was not meeting standard 19. Improvements were noted in the standard of moving equipment. None of the residents has capacity to self-medicate and the home has a satisfactory system in place to manage and administer their medication. Some personalised O.T. equipment required updating and a requirement is made under Standard 19 Regulation 13 (1) (b) The manager must continue her efforts to obtain O.T. assessments for residents and have equipment replaced accordingly. EVIDENCE: The manager has taken steps to improve Occupational Therapy services to all residents with regards to updating their equipment. Some of the residents’ personal O.T. equipment was in need of replacement. The manager has experienced difficulties in establishing which health authority (ie. The placing authority or the resident authority) has responsibility for these young people. Her efforts in this have been ongoing with various social services departments 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 15 and health authorities. She was awaiting responses to her enquiries at the time of inspection. There was evidence in care plans of consultation with residents and their representatives as to the care and support to be provided in the home (which does not provide nursing care). All residents are registered with a local G.P. and regular therapeutic programmes have been established with physiotherapists, as an element of ongoing care. Following assessment of residents’ disabilities and their capacity, all prescribed medication is managed and administered by the staff. Medication is locked in the kitchen when not in use and the key secured. Medication is signed for, by staff, at the time it is administered and the keys are signed over at the end of shift. There is an audit trail of refused medication and drugs returned to the pharmacy. Staff who administer medication receive an in-house training course and a course from an external provider is also available. The home has a written procedure to be followed in administering prescribed medication. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 16 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) x The home was not measured against these standards. EVIDENCE: N/A 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 17 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24,25,29 and 30. The home was meeting standards 24,25 and 30. The environment appeared to be meeting the needs of the young people who live there, at the time of inspection. Improvements have been made to moving and handling systems since the last inspection, however, shortfalls were noted with regards to standard 29 (regarding disability equipment) and a requirement has been made under Standard 19, Regulation 13 (1) (b). EVIDENCE: The home is purpose built and is furnished in a comfortable domestic style. There was a relaxed atmosphere and temperatures in the home are adjusted in keeping with the seasons and personal needs. Residents’ bedrooms are highly personalised with décor appropriate to a young lifestyle. The home was clean and hygienic at the time of inspection. The home is single-storey with wide doorways and two assisted bathrooms, accessed from bedrooms. All rooms are accessed by a broad corridor, which is suitable for wheelchairs and for the resident who has some independent 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 18 mobility. There is level access to the front car park and rear garden. The home has the use of the mini-bus, also used by other services of Parkhaven Trust. Due to their high levels of disability, residents require a number of aids and adaptations to accommodate their mobility and support. Ceiling tracking has now been fitted throughout the home, to assist with use of the hoist for the residents. A range of personalised equipment is in place for residents, such as wheelchairs, moulded seating, support jackets and limb splints. The problems experienced by the manager have been with regards to replacement of personal O.T. equipment for the residents. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 19 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) 35 The home was meeting standard 35. The organisation supports ongoing staff training and development and staff receive ongoing supervision and appraisals. There are some newly appointed staff in post in Westover Close, since the last inspection. EVIDENCE: The manager produced staff supervision and appraisal lists. Staff are in contact with the manager on a daily basis and will also receive one-to-one, confidential supervision sessions with Mrs. Bridgewater, (every two months). They will also receive ongoing appraisals to support their training and development needs. The manager may also wish to discuss with staff any problems they may have experienced in the use of wheelchairs in the general area, ie with regards to gradients. The manager is included on the roster and has two supernumerary shifts per week to undertake management duties. The staff training schedule was read, recent and arranged training includes Basic Food Hygiene, First Aid, Health and Safety, Equal Opportunities, Stress Awareness. Over 50 of staff have achieved NVQ Level 2 or 3. During their appraisals, staff have expressed an interest attending a training course in report writing. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 20 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. Service users’ rights and best interests are safeguarded by the home’s record keeping policies and procedures. The health, safety and welfare of service users are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 and 42 The home was not meeting Standard 37 as the manager is not yet registered with CSCI. A requirement is made under Standard 37 Regulation 8 (1) (2), that the manager must make application to CSCI for registration. The home was not meeting standard 42, which was assessed as to fire safety under 42.2 (ii), and 42.6 as to risk assessments. Requirements are made under Regulation 23, 4 (a) and (e) that the manager arranges regular fire drills and undertakes/updates the fire risk assessment for the home. EVIDENCE: The manager, Mrs. Bridgewater, is newly appointed. Her application for registration with CSCI had not been made at the time of inspection (received at the time of report). The fire risk assessment was in need of updating and the last fire drill undertaken had been in November 04. The last fire instruction for staff is on record as May 05. The home has a fire instruction video, which is held on the premises. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 3 3 Standard No 22 23 ENVIRONMENT Score x x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 2 3 x 2 x Score Standard No 24 25 26 27 28 29 30 STAFFING Score 3 3 x x x 2 3 Standard No 11 12 13 14 15 16 17 3 x x x x x 3 Standard No 31 32 33 34 35 36 Score x x 3 x 3 x CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 1c Westover Close Score 3 1 3 x Standard No 37 38 39 40 41 42 43 Score x x x x x 2 x F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 22 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 YA9 Regulation 13(4)(a) Requirement The manager must ensure that environmental risk assessments are carried out regarding one residents mobility and that the risk assessments are regularly reviewed. The manager must ensure that care plan reviews are kept up to date. The manager must continue her efforts to obtain O.T. assessments and have equipment replaced. Ongoing from the date stated. The manager must arrange regular fire drills and undertake/update the fire risk assessment for the home. The manager must make application to CSCI for registration. Timescale for action By 16/9/05 2. 3. YA6 YA19 and 29 15(2)(b) 13 (1) (b) By 16/9/05 20/7/05 4. YA42 (2) (ii) (6) YA37 23 (4) (a) and (e) 8 (1) (2) 30/7/05 5. 30/7/05 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 Good Practice Recommendations F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 23 1c Westover Close 1. Standard YA6 The manager should ensure that care plans are maintained in appropriate language. 1c Westover Close F53 F03 S5436 Westover Close V242190 190705 Stage 4.doc Version 1.40 Page 24 Commission for Social Care Inspection Burlington House, South Wing, 2nd Floor Crosby Road North Waterloo, 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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