Inspection on 13/02/07 for Christchurch Court

This inspection was carried out on 13th February 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 3 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Christchurch Court 21/11/05

Christchurch Court 12/07/05

Christchurch Court 24/01/05

Christchurch Court 17/06/04

Christchurch Court 02/02/04

Similar services:

Trevayler Residential Care Home

Thornham Grove

Thistle Hill Hall

Conifer Lodge

Westwood Lodge

Egerton Lodge Care Home

Alfred Minto House Care Home

St Matthews Unit

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

CARE HOME ADULTS 18-65 Christchurch Court 2 Christchurch Road Abington Northampton Northants NN1 5LL Lead Inspector Keith Charlton Key Unannounced Inspection 13th February 2007 10:00 Christchurch Court DS0000012742.V330383.R02.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 Christchurch Court DS0000012742.V330383.R02.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. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Christchurch Court Address 2 Christchurch Road Abington Northampton Northants NN1 5LL 01604 639838 01604 631895 enquiries@christchurchcourt.co.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) Marigold Contracts Limited Vacant Care Home 21 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (21) of places Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Christchurch Court care home is registered to provide personal care to male and female service users who fall within the following categories: Mental Disorder (21) The age range of service users is between 19 - 65 years. Christchurch Court can accommodate one named service user who is over the age of 65 and who also has a physical disability. All service users accommodated at Christchurch Court will have an acquired brain injury. The maximum number of persons to be accommodated at Christchurch Court is 21. 21st November 2005 Date of last inspection Brief Description of the Service: Christchurch Court is a care home providing personal care and accommodation for 23 service users with Mental Disorder with all service users having an acquired brain injury. The age range of service users is 19 to 65 years with an additional condition that the home may continue to provide care for one existing named service user over the age of 65 years. The Home is owned by Marigold Contracts Ltd. It is located in a suburb of Northampton, close to a local shopping centre and nearby park, easily accessible by public transport. The premises consist of a two-storey building offering all single room accommodation, with bedrooms having en-suite facilities. There are a choice of lounge areas, a dining room and small lounge smoking area. The Home does not have a lift. There is a courtyard garden area. Fees are typically £291 per day – this information was provided before the day of the inspection. The Acting Manager stated that fees are all inclusive with no charges for any extras. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The focus of the inspections undertaken by the Commission for Social Care Inspection is upon outcomes for service user and their views of the service provided… The primary method of inspection used was ‘case tracking’ which involved selecting three service users and tracking the care they received through looking at their records, discussion, where possible, with them and care staff and observation of care practices. This was an unannounced Inspection. The Acting Managers were on duty to assist with the inspection process. Other management staff also assisted. Planning for the inspection included looking at the last Inspection Report and assessing any notifications of significant events sent to the Commission for Social Care Inspection by the home. There have been no complaints received by the Commission regarding the home in the past year. The inspections took place between 10.00 and 16.00 on day one and completed the following day, and included a selected tour of the building, inspection of records and indirect observation of care practices. The inspector spoke with six residents, three members of staff, the training manager, a director and the two Acting Managers. There was a self-assessment questionnaire from the home available for this inspection with twenty Comment Cards completed by residents as to their views regarding the quality of care they receive. This was an impressive rate of completion of Comment Cards. What the service does well: Residents have very comprehensive, useful and up to date assessments of their needs. This ensures that the care received is tailored made to meet their requirements and enable them to live fulfilling lifestyles and routines that promote their rights as individual members of the community. The service focuses on residents’ individual needs, e.g. residents spoken with said they liked living in the home and thought staff were friendly, the food was good and they liked their bedrooms. Care Plans are comprehensive and detailed to assist staff to deliver care that fits individual service users care needs. Individual Activities Programmes help residents plan their time, provide stimulation and assist them to work towards their goals. A weekly session with their keyworkers means that programmes can be refined and extra support given to residents. Management arranges residents meetings to provide Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 6 information about services and asks their views about them. The minutes kept are detailed and clear. The training manager is proactive in planning for staff training. A choice of foods is always available to service users and there is an emphasis on healthy eating. Staff were found to be positive, friendly and helpful in their dealings with residents. Bedrooms are personalised and homely and organised to residents’ styles of living with a large amount of possessions in them to make them homely. Facilities have been recently upgraded and attractive, are bright and well furnished, and kept in a clean, tidy and odour free condition. What has improved since the last inspection? What they could do better: As there were a large range of comment about the service from very positive, to negative (in a small number of responses) it was recommended that independent advocacy is sought that can assist the service to fully comprehend residents views and develop an Action Plan to improve services as necessary. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 7 Staff need to ensure that medical authorities are always referred to if residents have potentially serious accidents, e.g. head injuries following a fall. There needs to be greater awareness regarding what constitutes a complaint from residents and ensuring that all relevant agencies are contacted if possible abuse has occurred between residents. Residents have some concerns regarding the reduction of space available to smoke, which could also exacerbate the consequences of one resident’s behaviour to other residents. In order to deal with this and promote residents’ choices, it is recommended that the company review this issue and increase facilities. 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. Christchurch Court DS0000012742.V330383.R02.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 Christchurch Court DS0000012742.V330383.R02.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): 2 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. A thorough assessment system to meet residents’ needs is in place, which ensures that an appropriate service can be provided. EVIDENCE: Residents said that that they stayed in the home for a trial period before making up their minds about coming to live there. The main Acting Manager said that a trial period is available for residents to sample living at the home before becoming confirming a permanent stay. Evidence seen by the inspector showed that there are detailed social work assessments and assessments completed by management prior to the admission of residents. Residents spoken with confirmed that they had received copies of the home’s information - Statement of Purpose and Service Users Guide. Most Comment Cards completed by residents supported this though some stated they had not Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 10 received the information – the Acting Manager said this would be resupplied where needed. Residents are also provided with information on independent advocacy services and a staff member has a designated role as residents advocate. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 11 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): 6,7,9 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The individual needs and choices of people living in the home are generally well met. EVIDENCE: Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 12 Residents spoken with thought they were well looked after and no one thought they were restricted in any way. The inspector case tracked three care records, which again clearly demonstrated that service users changing needs are being monitored and supported whilst living at the home. Care Plans are detailed and extensive. There was one Care Plan without a signature from a resident agreeing to the plan, and the residents comments section was blank – the Acting Manager said this would be followed up. Reviews are very well recorded and there is a weekly meeting that residents have with their keyworkers, which focuses on helping residents to meet their needs and aspirations, which was seen by the inspector to be very well recorded. Evidence was seen of a range of risk assessments, which addressed activities chosen by residents that may present risk. These included safety in the community. Risk assessments identified aspects of each resident’s care needs that resulted in increased vulnerability. This is good practice. Residents said they can make decisions about their own lives wherever possible e.g. what time to get up and go to bed, where they want to go on holiday, when they want to bathe, etc. They are asked their views on important issues in their meetings and these are recorded regarding food, holidays, outings etc. There has been some discussion as to the home obtaining a cat. Management may wish to revisit this issue to look at its feasibility, as it could enhance residents quality of life. Staff said that residents independence is always encouraged, as it is an essential part of the philosophy of the home. As the service focuses on rehabilitation, there is a signed agreement as to any restrictions on their right to choose, to protect their welfare and safety – e.g. going out on their own. It is recommended that residents have representation in staff meetings, if they wish, so as to increase their voice as to the running of the service. Currently they can be involved in staff interviews. This situation is commended. Staff spoken with were knowledgeable about the care and support each service user required. Staff were observed offering choices to service users, e.g. choice of food for lunch. Comment Cards were largely supportive of a residents right to choose though there were a number that said they were either never or only sometimes make decisions as to what they wanted to do each day. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 13 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): 12,13,15,16,17 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents living at the home have the opportunity to have a fulfilling lifestyle. EVIDENCE: Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 14 Residents spoken to said they could do what they wanted to do and that they liked going out. A resident said that staff were going to go on holiday with her this year, which she appreciated. Another resident said she was going to see a music concert in France and staff were helping her to plan for this. All residents have a weekly activities programme, which is agreed with them and they can make requests to change what they want to do. This is available for them at all times to refer to. There was evidence of a large range of activities –music, cooking, going out to activities – colleges, discos, local pubs etc. Records showed that residents have been on trips and are asked where they want to go on holiday. Residents Meeting notes showed that they have been consulted and trips are planned in the future. There were comments that residents want to have more group, as well as individual outings. The Acting Manager said this would be looked into. Staff said that residents use a range of community facilities including local shops, pubs, the park, the post office to get their money out etc. Residents said they could have their visitors to the home and that there were no real restrictions on visiting times - visitors were asked to leave by 11.30 pm, which was seen as reasonable. Residents said they were encouraged to keep in contact with their families and there was evidence on a weekly programme as to a resident ringing his mother a number of times in the week. A staff member said that it was important for residents to maintain contact with their friends and family. The service users guide includes a statement that residents are entitled to have intimate relationships if they choose, with advice and support available as needed. Residents all said the food was good or excellent. Food records showed that service users were given a wide range of choices of food. The lunch tasted was of a good standard with a choice of food, with salad as part of the meal, thereby encouraging healthy eating. Staff were seen to be offering residents a choice of food, and a resident was helped to eat his meal. There was an emphasis on Care Plans as to healthy eating. Comment Cards largely stated that staff treated residents well, which was supported by comments made to the inspector by residents. There were a small number of comments made that stated this was not always the case and a comment that residents were sometimes treated like children. This comment was also made in the home’s Quality Assurance survey completed by residents. The Acting Manager and Director stated that this would be raised in a general way with staff in a staff meeting, to ensure that their approach to residents is always friendly and respectful. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 15 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 receive good personal support with their physical and emotional health needs generally being well met. EVIDENCE: Residents said that if they were unwell then they would see the GP, and staff reminded them as to their medical appointments. They confirmed staff helped them as to their personal care needs and that they could speak to staff if they were anxious or unhappy. There is a very comprehensive information kept which details all medical appointments and check ups on an individual basis - from nurses, GPs, dentist, etc. Care Plans indicate all aspects of service users health care needs are covered – e.g. management of personal care, monitoring weight, communication, social skills, work and play etc. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 16 Accident/Incident Records were checked and it was found that staff had not always referred to medical authorities when residents had potentially serious accidents, e.g. head injuries following a fall. The Acting Manager said he would draw up a simple procedure to effect this for future accidents. Staff and management stated that all staff that issue medication have been trained by a distance learning method and also by the home’s training manager, who also has six sessions with staff to ensure they are competent to safely issue medication. This is seen as a good system and is commended by the inspector. The home has a policy and procedure for the safe administration of medications to ensure medication is issued and recorded appropriately. Medication records were checked and found to be up to date, with only a small number of gaps, which the Acting Manager said would be followed up. Medication is kept securely locked away. The controlled medication record and returns record were checked, and found to be properly maintained. The Acting Manager stated that it is policy that residents can handle their own medication if capable and this is currently the case for one resident at present. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 17 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 adequate. This judgement has been made using available evidence including a visit to this service. Residents’ welfare has not always been protected by robust procedures though there was also positive evidence that residents’ views are listened to and acted upon. EVIDENCE: Residents said that if they were worried about anything they would speak to staff or the Manager and they generally thought it would be followed up. The Pre Inspection Questionnaire that an Acting Manager provided prior to the inspection, stated that there have been six complaints with five being substantiated and one being partly substantiated, which positively reflects the openness of the service to critically examine how it works. A resident said that she had reported her concerns regarding another resident’s behaviour towards her and did not think this had been followed up fully by the home. The Acting Manager said that there have been measures put in place to ensure welfare was protected but agreed that the appropriate authorities had not been notified in this instance - he then contacted the appropriate agency to follow this up. Any incidents of this nature also need to be reported to the Commission for Social Care Inspection as a Regulation 37 incident. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 18 It was also agreed with the Acting Manager and Director that this and other residents concerns had not been interpreted or recorded as complaints and that management had recently discussed the need for greater staff awareness and recording procedures so that proper action was taken and seen to be taken. Comment Cards were generally very positive regarding the Complaints Procedure though one stated that a complaint had not been followed up. The Complaints Procedure seen by the inspector reflects the National Minimum Standard in that it stated that any complaints would be properly followed up and positively welcomes complaints so that the service can respond and follow up any issues if necessary. This is commended as good practice. There are residents meetings held where all residents are invited to attend and share their views about the home. A record of these meetings is available for residents and staff to refer to. Staff members on duty were asked about their understanding of whistle blowing procedures, and both demonstrated a good understanding of the protection of residents from abuse. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 19 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): 24,30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Residents live in a homely and comfortable environment, and standards of hygiene are very good. EVIDENCE: Residents said that they liked their bedrooms and they could have all their things in them. Residents Comment Cards stated that the home was kept fresh and clean. The home has now completed the building works and appeared to be attractive, homely and bright. Some residents showed the inspector their bedrooms. Observations of the bedrooms demonstrated that décor in their bedrooms suit their lifestyles. One resident said that she was able to make her bedroom into a music studio and able to buy her own furniture and this was found to be the case. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 20 Communal areas looked comfortable and clean. Standards of cleanliness and odour control in all areas of the home were good. There is a residents kitchen and the residents who aid they used these facilities were happy with the area. The only aspect of facilities that caused concern for some residents was that the smoking area had been reduced to a small space, and a residents said this limited space had caused her a problem due to the behaviour of another resident. This issue was also highlighted in a residents meeting minutes seen by the inspector. A Director said that this had been reviewed by the management and found to be satisfactory arrangement. Nevertheless, to promote residents choice and feeling of security it was recommended that this issue be reviewed again and facilities increased. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 21 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): 32,34,35 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from a dedicated staff group, with generally sufficient staff numbers on duty to meet residents needs. EVIDENCE: Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 22 Residents spoken to were very happy with staff and saw them as helpful and friendly. There were a number of comments made that there were not always enough staff on duty to ensure that residents were always able to pursue activities. The Director and Acting Manager said that this had already been recognised and there has been active staff recruitment to increase staffing levels by two staff on the pm shift. Staffing levels during the course of the inspection met the relevant minimum standards, in that there are eight care staff on duty during morning and six care staff on for pm periods, with two awake staff members on duty at night. The Registered Provider stated that these levels exceed the minimum standard. Staff records were inspected but and generally found to have all the necessary statutory checks, though identification was missing on one record. The Acting Manager said this would be followed up to ensure they are available for inspection. Information was subsequently received from the Director stating that this had now been resolved. Staff members were spoken to and had a good knowledge of service uses care needs and were again committed to providing a good service to residents. They said they were supplied with regular supervision, which was evidenced on a supervision chart. The training manager stated that there are approximately 60 of staff with a National Vocational Qualification level 2 qualifications and there is an active process to ensure that staff do National Vocational Qualification training in that they are enrolled after they have successfully completed induction and the probationary period. Staff spoken to said they were encouraged to undertake this training, which has the effect of attaining the 50 of staff needed to meet the National Minimum Standard. Staff have had training in a wide range of topics – Moving and Handling, Non Violent Crisis intervention, COSHH (Care of Substances Hazardous to Health), Acquired Brain Injury, Fire, Food Hygiene, etc. Training records are kept within individual staff files. New staff have to go through a detailed induction programme, based on the Skills for Care professional model. It was recommended that new staff receive training in Non Violent Crisis intervention and Acquired Brain Injury, as this is essential training that new staff will need from the time of the commencement of their employment. The Home operates a non-physical intervention policy. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 23 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): 37,39,41,42 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents benefit from the generally proactive management of the home. EVIDENCE: Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 24 Both residents and staff spoke highly of how the management runs the home. The Senior Staff Meeting notes seen are detailed and comprehensive and focus on ensuring staff meet residents care needs and the smooth running of the service. Service users have been asked as to their views on the way the home is run through a detailed Quality Assurance survey. The Acting Manager said he needed to analyse the results of surveys, to produce an Action Plan and include this information in the Statement of Purpose. Staff members were asked as to the fire procedure and were aware of this. Fire records showed that regular testing of and emergency lighting was in place and there are regular fire drills. A fire risk assessment was viewed though the new assessment could not be located. Fire bell testing was not always on the required weekly testing. The Acting Manager said that had been noted and that it is now checked weekly to see that it has been carried out. Most fire doors were open on approved devices though a fire door to the residents kitchen was found to be propped open though quickly shut when pointed out. The Acting Manager said this would be monitored in future. Some residents monies were checked and one found to be in deficit. The Acting Manager said this would be followed up and reported to the Commission for Social Care Inspection, or police if found to be necessary, as to why this was so. Information was subsequently received from the Director stating that this had already been picked up by the service and this had now been resolved. Records had receipts, running balances and a staff signature. Two signatures are recommended to ensure that all transactions are properly witnessed. The hot water temperature was measured and found to be within the National Minimum Standard at 45c, as the National Minimum Standard is close to 43c. There are fitted radiator covers to protest residents from burns. Health and Safety Policies and Procedures are in place and staff said they are encouraged to read them and have appropriate health and safety training. Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 25 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 4 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 4 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 X 3 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 3 15 4 16 3 17 4 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 1 3 X 3 X 3 X 1 3 X Christchurch Court DS0000012742.V330383.R02.S.doc Version 5.2 Page 26 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 YA19 Regulation 12 Requirement Staff need to refer residents to medical authorities if they receive potentially serious injuries. When Vulnerable Adults issues arise they must always be reported to the relevant Agencies. Resident’s monies records need to be kept up to date with any discrepancies fully detailed with action taken. Timescale for action 14/02/07 2. YA23 12 14/02/07 3. YA41 12 14/02/07 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard YA7 Good Practice Recommendations It is recommended that independent advocacy is sought that can assist the service to fully comprehend residents views and develop an Action Plan to improve services as necessary. As some residents have concerns regarding the reduction of space available to smoke, it is recommended that the company review this issue and increase facilities. DS0000012742.V330383.R02.S.doc Version 5.2 Page 27 2. YA7 Christchurch Court Commission for Social Care Inspection Derbyshire Area Office Cardinal Square Nottingham Road Derby DE1 3QT 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. 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