Inspection on 19/03/07 for 53 Churchfields

This inspection was carried out on 19th March 2007.

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 no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

53 Churchfields 13/08/07

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Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOME ADULTS 18-65 53 Churchfields Headley Down Bordon Hampshire GU35 8PE Lead Inspector Craig Willis Unannounced Inspection 19th March 2007 10:30 53 Churchfields DS0000068500.V335391.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 53 Churchfields DS0000068500.V335391.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. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service 53 Churchfields Address Headley Down Bordon Hampshire GU35 8PE 01428 713308 F/P 01428 713308 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) Omega Elifar Ltd Post Vacant Care Home 4 Category(ies) of Learning disability (4) registration, with number of places 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection This is the fist inspection since the service has been managed by Omega Elifar Ltd. Brief Description of the Service: 53 Churchfields is registered to provide care and accommodation to four people who have learning disabilities. Each service user has a single bedroom and shares the use a bathroom and shower room. One of the bedrooms has an ensuite shower room. Service users share the use of a lounge / dining room, kitchen and conservatory. There is an enclosed garden to the rear of the home that service users are able to access. The home is located in a residential area of Headley. The community services manager reported in the pre-inspection questionnaire that the fee for the home is £1,250 per week. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The evidence used to write this report was gained from a review of the preinspection questionnaire the provider sent to the Commission for Social Care Inspection (CSCI) and a site visit to the home on 19 March 2007. During the site visit the inspector spoke with two of the service users, observed the interactions between service users and staff and spoke with the staff on duty, including the acting manager and community service manager. A CSCI comment card was received from one of the service users. What the service does well: What has improved since the last inspection? What they could do better: Better records need to be kept of medication people are supported to take. This will help to ensure people do not miss or take too much of their medication. The provider needs to make sure that the systems for staff to report incidents affecting people’s safety work better. This will enable quick action to be taken to protect people. A full record of training staff attend needs to be kept. This will help the manager to plan training that staff need. The provider needs to make sure that the quality assurance system that has been developed is implemented. This will help to plan improvements to the home. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 6 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. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 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 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standard 2. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There are good systems to assess the needs of service users before they move into the home. EVIDENCE: The files of all three service users currently living at the home were inspected during the visit. Each contained an assessment of their needs that was completed before they moved into the home. This assessment covers the individual needs of service users, including physical, communication, personal care and cultural needs. The acting manager reported that as part of the assessment process potential service users are encouraged to visit the home to meet with service users and staff. Service users move into the home on an initial three-month trial period, during which formal assessments of whether the home is meeting the service user’s needs and how they are settling in will be completed. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 6, 7 and 9. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has good care planning and risk assessment systems, which supports service users to make decisions about their lives and take managed risks. EVIDENCE: The personal files of all three service users currently living at the home were inspected during the visit. Each service user had a care plan that was developed from their initial needs assessment. These plans are reviewed monthly and had been changed where the needs of the service user had changed. Where necessary other professionals had been consulted in the development of plans, for example, a GP and neurologist had signed one service user’s epilepsy plan and one service user’s socialisation and behaviour plan had been signed by their care manager. Care plans contain details of how service users should be supported to make decisions and how staff should present options. During the visit staff were observed supporting service users to make choices 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 10 Risk assessments were in place for all service users. These documents set out the assessed hazards to service users and action to minimise the risk of harm. Most of the risk assessments had a date for review, which is either weekly, fortnightly, monthly or six monthly depending on the risks involved. It was noted that some of the risk assessments had not been signed and dated by the person completing them. The acting manager agreed to ensure that this was completed. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12, 13, 15, 16 and 17. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides good support for service users to take part in suitable activities, to maintain relationships with family and friends and to have a balanced diet of food they enjoy. Staff work in a manner that respects the rights and responsibilities of service users. EVIDENCE: Service users are supported to take part in a range of educational and leisure activities, including attending a local day service, photography, pub visits, gardening, drumming, swimming and using a gym. Service users spoken with said they enjoyed their activities and there were enough staff to support them. The CSCI comment card that was received from a service user said they were able to do what they wanted to at the weekends and in the evenings. The home has an open visiting policy and service users are supported to keep in touch with family and friends. Staff were observed providing support in a friendly and respectful way, which maintained the privacy and dignity of service users. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 12 The home has a planned menu that takes into account the likes and dislikes of service users and provides a varied and balanced diet. Mealtimes are flexible to fit in with service users’ activities. The kitchen was well stocked with a variety of good quality food. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 13 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 18, 19 and 20. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home provides good support to meet the personal care and health needs of service users. Medication is safely stored, however, the system for recording medication is not sufficiently robust to ensure service users are protected. EVIDENCE: Details of the personal care support service users need are set out in their care plans. Service users spoken with said that staff treat them well and listen to them. This was also reported in a CSCI comment card received from a service user. Staff spoken with demonstrated a good understanding of the needs of service users. Records are maintained of service users’ visits to health services, including GP, dentist, neurologist and psychiatrist. The records kept included details of any advice given by the practitioner. Medication is stored in a locked cabinet in the office and records are maintained of medication brought into the home, administered and returned to the pharmacist. The medication inspection records were inspected and it was noted that there were three occasions in the current month where there was 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 14 no record that medication had been administered. The acting manager said she thought this was when medication was not required or had been refused, but could not be certain. The acting manager said she would follow this up to ensure all staff are clear of their responsibilities when administering medication. All other medication records had been fully completed and all staff administering medication have received training. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 15 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): Standards 22 and 23. Quality in this outcome area is poor. This judgement has been made using available evidence including a visit to this service. There are systems in place for service users to complain, although the way staff record and report incidents does not ensure service users are protected. EVIDENCE: The home has a complaints procedure available, which sets out who will deal with a complaint and how long the provider will take to respond. The procedure has been supplied to all service users in an accessible pictorial format. One service user who completed a CSCI comment card said they know what to do if they want to make a complaint. No complaints have been received by the home or CSCI since Omega Elifar has managed the home. The acting manager was not sure how many of the staff have received training in abuse and safeguarding adults, although did report that all staff were completing training in the week following the inspection. Staff spoken with had a good understanding of types of abuse and action they should take if abuse is reported, witnessed or suspected. The home’s incident records were inspected as part of the visit. It was noted that an incident had been recorded in February 2007 where one service user had slapped another on the cheek. The acting manager said she was not aware of this incident, as it had not been reported to her. It was agreed with the acting manager during the visit that she will make a referral to the adult protection team in adult services and review the risk assessments and support plans to ensure service users are kept safe. The acting manager will also ensure all staff are aware of how to report incidents. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 16 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): Standards 24 and 30. 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 maintained and provides a safe, homely environment for service users. EVIDENCE: The home has recently been refurbished and a tour of the communal areas of the home was made during the visit. The home is well maintained and decorated throughout. The acting manager reported that service users were consulted about the style of decorations and furnishings during the refurbishment. All areas of the home were clean during the visit and one service user reported in a CSCI comment card that the home was always clean and fresh. The home has an enclosed rear garden that service users are able to access. Staff reported that work was planned to ensure the garden was tidied up for use in the summer. The home has a separate laundry room, which means laundry is not taken through food preparation or storage areas. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 17 There are hand-washing facilities in the kitchen, laundry room, bathrooms and toilets. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 18 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): Standards 32, 34 and 35. Quality in this outcome area is good This judgement has been made using available evidence including a visit to this service. The home has good recruitment procedures and staff training programme, which helps to ensure service users are protected. EVIDENCE: The acting manager reported that four of the thirteen staff have achieved the National Vocational Qualification (NVQ) at level 2 or above and four staff are currently completing NVQs at level 2, 3 or 4. During the visit, staff were observed interacting with service users in a friendly and respectful manner. The records of three members of staff were inspected during the visit. These were all new members of staff that had been employed since December 2006. These records demonstrated that the home had obtained a Criminal Records Bureau disclosure and written references prior to them starting work. Potential staff complete an application form and provide information about their health and work history before they are interviewed. Staff spoken with said that they received good training, which helps them to meet the needs of service users. The acting manager reported that the home does not have a record of all staff training that has been undertaken. As a result, a training needs analysis has just been undertaken and where gaps have been identified training courses are being planned, for example, all staff 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 19 were due to complete adult protection training in the week following the inspection. Courses staff have completed include first aid, medication administration, moving and handling, food hygiene, fire safety, health and safety, physical interventions and epilepsy. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 37, 39 and 42. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The provider has made suitable arrangements to run the home in the absence of a permanent manager, however, the lack of a fully implemented quality assurance system does not ensure the home systematically identifies and plans improvements. EVIDENCE: The previous registered manager left on 9 March 2007 and the home currently has an acting manager, who is supported by the company’s community service manager. The acting manager said she receives good support and is able to speak with the community service manager whenever she needs to. Staff spoken with said they receive good support from the acting manager. The acting manager reported that the company was currently in the process of recruiting a new permanent manager. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 21 The home has sent out questionnaires to relatives to gain their views of the quality of the service that is being provided. The acting manager reported that it is planned that this survey will be extended to include professionals who have contact with the home, such as GPs and care managers. The company has a quality assurance system that assesses all areas of service quality over a twelve month period, although it has not yet been implemented. This system will be used to create development plans. The acting manager was not aware of when the system will be implemented. Service users have weekly meetings, when they can say what they think about the way the home is managed. Senior managers from the organisation visit the home each month to review the service quality. Reports of these visits contain actions that are required to improve the service. The home has a fire risk assessment and regular checks are made of the fire warning system and the equipment. There are risk assessments for the building, which contain actions that should be followed to minimise the identified risks. The gas boiler is serviced annually and annual tests of portable electrical appliances are completed. Assessments are completed for chemicals used in the home, which are stored in a locked cupboard. The temperatures of the fridge and freezer are taken daily and recorded. The home has systems for recording and reporting accidents and incidents, although as previously reported in the Concerns, Complaints and Protection section of this report, this system has not ensured that the acting manager is aware of all incidents in the home. The acting manager is taking action to ensure all staff are aware of the procedures to follow and service users are kept safe. 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 X 2 3 3 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 1 ENVIRONMENT Standard No Score 24 3 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 2 X 3 X 2 X X 2 X 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? N/A 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 YA20 Regulation 13 (2) Requirement The registered person must ensure that records are kept of medication administered to service users. These records must include details of any reasons why medication is not taken as it has been prescribed. The registered person must ensure that all staff are aware of the procedures to follow to report incidents affecting the well-being or safety of service users. Timescale for action 30/04/07 2 YA23 13 (6) 30/04/07 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 Standard Good Practice Recommendations 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Hampshire Office 4th Floor Overline House Blechynden Terrace Southampton SO15 1GW 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 53 Churchfields DS0000068500.V335391.R01.S.doc Version 5.2 Page 25 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. 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