Care Home: Childwall Brook

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What the care home does well Residents were very positive about most aspects of the home and the support provided to them. Each resident has a detailed care plan. The level of information in these is very good and they provide a clear guide as to the needs of the person and how these are to be met. The care plans include information on the person`s strengths and needs and include goals for supporting the person to develop their skills and aim for a more independent lifestyle. Residents meet with their key worker on a regular basis to review their care plan and decide whether or not there should be any changes to their support. Resident meetings take place on a regular basis and residents are also given further opportunities to comment on the home through questionnaires. Residents are supported to remain healthy and staff support the residents to attend health appointments on a regular basis. Staff also support residents with their emotional and psychological well being. Staff support the residents with developing their personal and independent living skills and using the local community. The turnover of staff is low and therefore many of the staff have been supporting the residents for a long period of time and have had the opportunity to build relationships with them and to know their needs well. A high percentage of staff are qualified to a National Vocational Qualification (N.V.Q) level 2 in care. Staff are also provided with a good level of training and this covers topics such as mental health awareness, person centred planning, care and responsibility, health and safety, first aid, food hygiene, moving and handling, fire awareness. Health and safety procedures are in place so as to ensure the home environment is safe to residents, staff and visitors. The home is well organised and is run in the best interests of the residents. What has improved since the last inspection? The manager reported that links with other agencies are being developed and a number of residents are now using a greater number of community resources. The system for the recording of particular medications has been improved and is now to the required standard. A new system for identifying staff responsibilities for the duration of their shift has been introduced and this was reported to be working well. The home now has internet access and this is reported to be an asset to the service. What the care home could do better: The registered manager left the home approximately 5 months ago. There have been temporary management arrangements in place since then. A manager needs to be appointed to the home and when appointed this person will need to apply to the Commission for registration as manager. A new system for recording when a resident has been seen by a health professional needs to be implemented. This is to ensure that this sort of information is much more readily accessible when required.The home environment is presented and maintained to a satisfactory standard. However, there are some areas which could be improved upon withredecoration and refurbishment. The manager reported that the home is due for refurbishment in the near future. CARE HOME ADULTS 18-65 Childwall Brook 30 St Paschal Baylon Boulevard Childwall Liverpool Merseyside L16 3NY Lead Inspector Debbie Corcoran Key Unannounced Inspection 6th November 2007 10:00 Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Childwall Brook Address 30 St Paschal Baylon Boulevard Childwall Liverpool Merseyside L16 3NY 0151 738 0353 0151 738 0354 stuart.oleary@alternativefuturesgroup.org.uk 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) Alternative Futures Limited ** Post Vacant *** Care Home 20 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (20) of places Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Residents between ages of 16 - 64 years To accommodate one named female over 64 years old. Date of last inspection 1st August 2006 Brief Description of the Service: Childwall Brook is a care home registered with CSCI to provide 24 hour nursing care support for 20 adults with enduring mental illness. The home is owned and managed by Alternative Futures, a registered charity that offers a range of facilities throughout the North West of England. The home is located in the Childwall area of Liverpool and has easy access to bus routes, shops, pubs and other amenities. Childwall Brook is a single storey, purpose built establishment that was opened in 1993. It is set in its own grounds and there are gardens to all aspects. The accommodation is made up of 18 single bedrooms and two self-contained bed sits. 10 of the bedrooms and the two bed-sits have en-suite facilities. Communal space in the home consists of a number of lounges, conservatories, a rehabilitation kitchen and games room. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The visit to the home was not announced beforehand. During the visit the majority of the residents were met and spoken with and a number were spoken with on a one to one basis. Members of the staff team were also spoken with. A sample of resident’s records were looked at. Other records looked at included staff training records and health and safety records. A tour of the home was carried out which included all areas. The manager returned a quality assurance assessment on the service to the Commission. Some of the information contained in this has been used to inform the findings of the inspection. In addition to this a number of residents and members of staff returned surveys to the Commission and information gained from these has also been used to inform the findings of the inspection. What the service does well: Residents were very positive about most aspects of the home and the support provided to them. Each resident has a detailed care plan. The level of information in these is very good and they provide a clear guide as to the needs of the person and how these are to be met. The care plans include information on the person’s strengths and needs and include goals for supporting the person to develop their skills and aim for a more independent lifestyle. Residents meet with their key worker on a regular basis to review their care plan and decide whether or not there should be any changes to their support. Resident meetings take place on a regular basis and residents are also given further opportunities to comment on the home through questionnaires. Residents are supported to remain healthy and staff support the residents to attend health appointments on a regular basis. Staff also support residents with their emotional and psychological well being. Staff support the residents with developing their personal and independent living skills and using the local community. The turnover of staff is low and therefore many of the staff have been supporting the residents for a long period of time and have had the opportunity to build relationships with them and to know their needs well. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 6 A high percentage of staff are qualified to a National Vocational Qualification (N.V.Q) level 2 in care. Staff are also provided with a good level of training and this covers topics such as mental health awareness, person centred planning, care and responsibility, health and safety, first aid, food hygiene, moving and handling, fire awareness. Health and safety procedures are in place so as to ensure the home environment is safe to residents, staff and visitors. The home is well organised and is run in the best interests of the residents. What has improved since the last inspection? What they could do better: The registered manager left the home approximately 5 months ago. There have been temporary management arrangements in place since then. A manager needs to be appointed to the home and when appointed this person will need to apply to the Commission for registration as manager. A new system for recording when a resident has been seen by a health professional needs to be implemented. This is to ensure that this sort of information is much more readily accessible when required. The home environment is presented and maintained to a satisfactory standard. However, there are some areas which could be improved upon with Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 7 redecoration and refurbishment. The manager reported that the home is due for refurbishment in the near future. 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. The summary of this inspection report can be made available in other formats on request. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 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 Outcomes Statutory Requirements Identified During the Inspection Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Information on the home was readily available. Systems are in place for ensuring the needs of prospective residents are assessed before they move to the home. EVIDENCE: Information on the services and facilities provided at the home is available for residents, prospective residents and other interested parties. The home has a statement of purpose. It was reported that this was under review and in the process of being amended to reflect changes to the management of the home. It was reported that 3 different booklets are being produced to provide relevant information to residents, to relatives / representatives and to staff. There had been no new residents admitted to the home since the last inspection visit and therefore the home assessment and referrals processes could not be practically assessed on this occasion. However, it was noted that resident’s records included assessment information. These assessments were comprehensive and included information on the person’s needs and strengths in areas such as their safety, self care, diet, physical health, social ability, education, expression, culture, religion, psychosocial history and their current psychological and mental health needs. There was also evidence that assessment information had been attained from other health professionals. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9, 10 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Each resident has a plan of care which clearly reflects their needs and choices and residents are encouraged to make decision about their life and the running of the home. Where a resident is thought to be at risk of harm information on this, and how to manage it, is recorded in their care plan. Resident’s confidentiality is protected by the arrangements for storing information. EVIDENCE: Care plans for three of the residents were looked at. These were found to be of a very good standard. Care plans were found to be comprehensive, clear, informative and easy to follow. The plans include information on the strengths and needs of the person in areas such as their mental health, physical health, health care, independent living skills and personal care. The level of information in the resident’s care plans was pitched really well so as to provide staff with important information on the needs of the person. The plans were Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 11 easy to follow and provided a description of the area of need followed by information on short term goals, long term goals and how to implement the plan. There was a good example of a plan referred to as a “Wellness recovery action plan” and this included information on what things the person does to keep well, things which need to be avoided to remain well, triggers that cause an increase in symptoms or experiences. There was evidence that residents are supported to try to understand their mental health needs. Part of the resident’s care plans focus upon the support the person requires to develop their independent living skills. These are in line with the needs and wishes of the resident. It was reported that residents have the opportunity to meet with their key worker on a monthly basis to review their care plan and make changes to their care plan. There was a particularly good example of a resident having been involved in a self assessment referred to as a “Personal futures plan”. This provides residents with the opportunity to discuss what they want for their short and long term future and asks how staff can help the person to achieve what they want for the future. It was reported that each resident has the opportunity to complete a “personal futures plan”. Residents are supported to take risks as part of an independent lifestyle. Where a resident is involved in activities which pose a risk to their safety then this is recorded in the person’s care plan along with information on what steps need to be taken to prevent the risk from occurring. Risk assessments were found to be up to date, reviewed on a regular basis are readily available to staff to read and be familiar with. The staff turnover is low and as a result many of the staff have worked at the home for a significant period of time and therefore they have had the opportunity to build relationships with the residents and to get to know the residents well. A number of residents spoken with were positive about all aspects of their support and appeared confident that staff were meeting their needs and providing good care and support. Residents who were spoken with said that they are making their own decisions as to their daily support and their routines within the home. Residents have the opportunity to attend residents meetings whereby they can discuss the running of the home with staff on a more formal basis. All personal and confidential information is stored appropriately and staff are aware of their responsibilities in this area. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported to develop their independent living skills, to develop and maintain relationships and to be involved in local community facilities. Residents are included in decision making on the running of the home. Residents are provided with a varied diet of home cooked food. EVIDENCE: Residents care plans include a good level of information on how to support the person with using and developing their independent living skills. From discussions with residents it was clear that they are supported to develop their independent living skills as appropriate to their individual needs. Residents are encouraged to make choices about the running of the home and their care. Residents confirmed that they are making choices and they gave examples such as choosing when to get up, when to go to bed, their meals, their daily routine, how to spend their day. Residents are supported to manage Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 13 their own affairs when possible, for example managing their own money and their own post. Residents are responsible for keeping their own rooms tidy and to do their own laundry. However, there is assistance from staff available. Residents are able to express their needs and preferences and contribute to changes at the home. Residents have the opportunity to attend a residents meeting on a regular basis and are given the opportunity to complete surveys to give feedback on the home. Residents generally gave good feedback on their support with pursuing leisure and social activities. Although a small number of residents said that they would like to go out more. Residents are going out and using community resources independently when they are able to and with support from staff when needed. The home has a designated member of staff referred to as a ‘rehabilitation coordinator’. The purpose of this person’s role is to consult with residents and plan a variety of recreational, community and educational activities. Discussions with residents and daily records confirmed that residents are supported in activities such as shopping, walking, games, going on day trips, and attending day services. The home is equipped with pool table, exercising equipment, board games, music, TV and video/DVD players. Most residents have their own TV and music systems. A number of residents visit the local church social club and the local pubs. The manager reported that the service is developing a greater number of links with community resources and residents are being supported to access these. The manager also reported that group work sessions are going to be introduced which are intended to give residents the opportunity to discuss issues and promote self help. In order to assess the meals and food provided the menu was looked at, the kitchen was checked including food storage and health safety in the kitchen, and a number of the residents were asked to comment on the food. The home has a designated cook who is responsible for the main meals of the day. The kitchen was found to be well organised. Food was stored in good supply and stored safely. The menu was varied and all feedback on the food and meals was positive. In addition to the main kitchen residents have access to a number of other areas for food and drink preparation. There is a domestic style kitchen which is used regularly by residents who are using their independent living skills and planning and preparing some of their own meals. The home also has two semi independent bedsits which have a kitchen area and the residents who reside in these areas are regularly provided with support to shop for their own meals and cook their own meals. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are well supported with their personal, emotional, physical and health care needs although there is room for improvement in how some of the information to show this is recorded. Medication is well managed overall. EVIDENCE: The resident’s care plans include a good level of information on how to support the person with their psychological, emotional and physical health and well being. During discussions with the residents they felt that staff support them well. One resident commented ‘staff know everything about me and how I feel’. Resident’s care plans include information on the resident’s needs with both their physical and mental health care needs. Regular reviews take place in relation to the resident’s mental health needs and the manager reported that a new system is being introduced which will mean that each resident has a weekly review of their mental health state. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 15 There is a trained psychiatric nurse on duty at all times. In addition to this residents are provided with good support from consultant psychiatrists and from visiting Community Nurses. Resident’s daily notes showed that residents are supported to remain healthy and to attend health related appointments. However, because this information is being recorded in the resident’s daily care notes it was difficult to establish the frequency of visits to a range of different health professionals. It is therefore strongly recommended that a new system of recording this information is used which makes it easy to identify when a resident has last seen, for example, a Psychiatrist, GP, nurse or dentist and what the outcome of the visit was. Medication storage was checked and a random sample of administration records were checked. These showed that medication is safely managed. Medication is administered by trained staff only. A number of practices could be improved. Staff should administer medication from one supply at a time as this makes auditing medication easier and may help to identify any mistakes in the administration of medication more readily. Staff should clearly record when a medication audit has been carried out. Where a medication has been changed by the prescriber then this information needs to be appropriately amended on the medication administration records at all times. None of the residents manage their own medication. Residents should be encouraged to manage their own medication when this is appropriate and following a risk assessment having been carried out to ensure that residents who do manage their own medication are able to do this safely. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Policies, procedures and practices are in place for dealing with complaints and for aiming to protect residents against abuse or neglect and systems are in place for dealing with allegations of abuse. EVIDENCE: The home has a complaints procedure which is time scaled appropriately and includes contact details for the Commission. A copy of the complaints procedure is available to residents and is on display in the main hallway. During discussions with residents they stated that if they weren’t happy about something then they would tell the staff. There have been no complaints made to the home since the last inspection. The home has an Adult protection procedure. This procedure provides information on adult protection and responsibilities for contacting relevant authorities. Trained staff have been provided with training in safeguarding adults. However, support staff have not been provided with this training. It is strongly recommended that safeguarding adults training is provided to all staff. A record of key events is maintained for example incident reports and accident reports. These were checked and found to be maintained appropriately and there were no particular areas of concern identified. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 26, 28, 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with a well maintained, comfortable and safe home environment. EVIDENCE: A tour of the home was carried out. The home was purpose built in 1993 and provides ground floor accommodation only. The home provides a variety of communal lounges. In addition to these there are a number of conservatories and an ‘activities’ room which has a pool table and sport and games equipment. Each of the residents has their own bedroom which they can lock for their privacy. A small sample of residents rooms were viewed and were found to be personalised with some of the residents own belongings. The home provides two bedsits which include a fitted kitchen and bathroom. These are designated for residents who may wish to move on from the home to a more independent Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 18 setting. A number of residents were asked about their rooms and they said that they were happy with them. The manager reported that the home is due for refurbishment. No requirements have been given in relation to the environment but it was evident that a number of areas would benefit from redecoration and refurbishment. The home has a main kitchen used by the catering staff to prepare main meals. In addition to this residents have use of a fully fitted domestic sized kitchen for their own use. The home has a large rear garden which is well maintained and provides a good amount of outdoor space for residents use. Health and safety practices and procedures are in place which are aimed at ensuring the home is safe, clean and free from hazards to residents and staff. Many of the residents’ smoke and there is a designated smoking room which is a conservatory. A number of residents were not happy that the television had been removed from this room due to changes in smoking legislation and in line with advise from the Environmental Health Department. During the tour of the home there was evidence to indicate that one of the residents is smoking outside of the designated smoking area. Assessments with regards to smoking are in place for each of the residents who do smoke. However, these do not include an assessment of the potential risks concerned. The manager must ensure that risk assessments are carried out and these should include information as to how to manage potential risks. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 32, 33, 34, 35, 36 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are supported by qualified, trained and well supported staff. Staff numbers are appropriate to ensure that the resident’s needs are being met effectively. EVIDENCE: There are clear lines of accountability across the staff team and roles and responsibilities of staff are clearly defined. The home employs Registered Mental Nurses (RMN) and there is an RMN on duty at all times. There are also support workers and ancillary staff employed. Discussions with the residents and staff indicated that staff are supporting the aims and objectives of the home in encouraging residents to make choices, develop their independent living skills and use their local community. Staff turnover is low and therefore many of the staff have been supporting the residents for a significant period of time and have had the opportunity to get to know the residents well. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 20 Residents gave positive feedback about the staff. One resident said that the office is always open and staff readily invite them in to talk about how they feel. Another resident said “staff understanding everything about me” and “you can always talk to the staff. You can go to the office anytime and staff will say come in, sit down and I can talk to them about anything”. A total of 11 of the 14 support workers employed have attained a National Vocational Qualification (N.V.Q) level 2 in care or above. The manager provided a staff training matrix which identifies the training which staff have been provided with and the date of the training. This showed that support staff are provided with a good level of training on a regular basis. This training includes topics such as mental health awareness, person centred planning, care and responsibility, health and safety, first aid, food hygiene, moving and handling and fire awareness. Trained nursing staff have been provided with additional training in topics such as the Mental Health Act, protection of vulnerable adults, performance management and investigations and disciplinary procedures. At the last inspection it was evidenced that staff recruitment and selection practices are thorough and aimed at protecting residents. There have been no new members of staff since the last inspection and therefore recruitment and selection procedures were not assessed on this occasion. Staff are provided with regular supervision meetings and regular team meetings take place. These provide an opportunity for staff to explore their practice, explore new ways of working and to make and communicate decisions as to how to develop the service. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 21 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. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well organised and is run in the best interests of the residents. The health, welfare and safety of residents and staff is promoted and protected. EVIDENCE: The registered manager left the home approximately 5 months ago and a temporary manager is in post. A new manager must be appointed to the home. This person will need to apply to the Commission for registration as manager. The home is well organised and all required information was readily available. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 22 Residents contribute to daily decision making in the home and alongside this residents are also invited to comment on the home through residents meetings and through completing surveys on the home on an annual basis. The home is visited by a representative from the organisation on a monthly basis and reports of these visits were available. Alongside this weekly and quarterly assessments are carried out on the home environment. The annual quality assurance questionnaire returned by the manager identified that polices and procedures are being reviewed on a regular basis. The home has numerous policies and procedures in relation to the health and safety of residents and staff and staff have been provided with training in core health and safety related skills. Fire safety and health and safety practices are adopted. Records of fire and health and safety checks were checked and found to be up to date. Risk assessments were in place for safe working practices and these are regularly reviewed. Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 23 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 3 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 3 ENVIRONMENT Standard No Score 24 3 25 3 26 3 27 X 28 3 29 X 30 3 STAFFING Standard No Score 31 3 32 4 33 3 34 3 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 4 3 3 3 3 LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 X 3 x Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 24 Are there any outstanding requirements from the last inspection? No 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 YA37 Regulation 9 Requirement An application for registration of a suitably skilled, experience and qualified manager must be made to the Commission. Timescale for action 06/01/08 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. Refer to Standard YA19 Good Practice Recommendations The manager should review the current system for recording when a resident has been supported to see a health professional or any other health related matters. Medication practices should be addressed as identified in the body of the report. All care staff should be provided with training in safeguarding adults. The manager should carry out risk assessments and ensure that risk management plans are put in place with regards to residents smoking on the premises. 2. 3. 4. YA20 YA23 YA24 Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Merseyside Area Office 2nd Floor South Wing Burlington House Crosby Road North Liverpool L22 0LG National Enquiry Line: Telephone: 0845 015 0120 or 0191 233 3323 Textphone: 0845 015 2255 or 0191 233 3588 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 Childwall Brook DS0000025094.V350988.R01.S.doc Version 5.2 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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