CARE HOMES FOR OLDER PEOPLE
Christian Head Silver Street Kirkby Stephen Cumbria CA17 4HA Lead Inspector
Paula Banham Unannounced Inspection 28 October 2005 10:15 X10015.doc Version 1.40 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 Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. 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. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION
Name of service Christian Head Address Silver Street Kirkby Stephen Cumbria CA17 4HA 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) 017683 71429 Cumbria Care Mrs Janet Sephton Care Home 33 Category(ies) of Dementia - over 65 years of age (10), Old age, registration, with number not falling within any other category (33) of places Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION
Conditions of registration: 1. 2. The service should at all times employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. The home is registered for a maximum of 33 service users to include: - up to 33 service users in the category of OP (Old age not falling within any other category) - up to 10 service users in the category of DE(E) (Dementia over 65 years of age) Two service users may share a bedroom of at least 16 sqm usable floor space only if they have made a positive choice to do so, and when one of the shared spaces becomes vacant the remaining service user has the opportunity to choose not to share, by moving to a different room if necessary. The staffing levels for the home must meet the Residential Forum Care Staffing Formula for Older Adults. 27/4/05 3. 4. Date of last inspection Brief Description of the Service: Christian Head is a residential care home registered with the Commission for Social Care Inspection to provide care and accommodation for up to thirtythree people over sixty-five years old. Accommodation for residents is provided in four living units, one of which specialises in providing care for people with dementia. The home is owned by Cumbria County Council and is carried on by Cumbria Care, a business unit of the County Council. The home is located next to the fire station, close to the centre of Kirkby Stephen. Christian Head is close to local shops and services including doctors surgeries, banks and churches. Mrs Janet Sephton is the registered manager, responsible for the day-to-day running of the home of the home. Accommodation for residents is provided over two floors in twenty-nine single bedrooms and two double bedrooms which two people can choose to share. Three bedrooms have ensuite facilities and there are appropriate toilet and bathing facilities close to all the accommodation provided for residents. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection was unannounced and was carried out on 28 October 2005 and 4 November 2005. The inspection focussed on how well the home meets the needs of the people living there. This was assessed by speaking to residents, care staff and the home manager, observing activity and examining the records care homes are required to hold. What the service does well: What has improved since the last inspection? What they could do better:
The registered manager has not completed the registered managers award. She should ensure that she registers for and completes this qualification to ensure she has up to date skills and continues to be competent to manage the home. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 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. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 4 and 6. Admissions to the home are well managed and residents know their needs will be met. Christian Head does not provide intermediate care. EVIDENCE: The home has a thorough admissions procedure which includes an assessment of residents’ needs. The needs assessments are used to ensure that the services and facilities provided in Christian Head are suitable to provide the care individuals require. Residents made many positive comments about the standard of care. One resident said, “I couldn’t have made a better decision than moving here”. Care staff are knowledgeable about residents’ needs and provide a high standard of care in a manner which promotes residents’ independence and meets their needs. Christian Head does not provide intermediate care and standard 6 does not apply to the home. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 9 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8 and 10. Residents’ personal and health care needs are identified and met by the support provided. Residents are treated with respect and their privacy and dignity are protected. EVIDENCE: Detailed records are held about the support which individuals require. Care staff are knowledgeable about the care residents need and provide this in a patient and friendly manner. Residents receive health care from local GP practices and from health care specialists as they require. Residents are supported to attend routine health care appointments including chiropody and dental services. Residents are treated with respect and appropriate actions are taken to maintain their privacy and dignity. Residents and their relatives said they are “very happy with the care provided”. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 10 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13. Residents benefit from a range of activities which provide them with recreation and stimulation. Residents receive maintain contact with their families and the local community as they wish. EVIDENCE: The home provides a variety of activities and residents receive appropriate recreation and stimulation. Residents choose whether to take part in the activities provided. The choice of activities has been discussed at meetings with residents and the home’s management team. As a result of the feedback from residents new activities have been provided and are planned. Residents receive visitors as they choose in Christian Head. Visitors are made welcome by the staff and appear comfortable in the home. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 11 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16. Residents and their families know how to complain about the home and that actions are taken to resolve their concerns. EVIDENCE: The home has a clear procedure for dealing with complaints. A copy of the complaints procedure is given to new residents and displayed in the home. Systems are in place to allow residents to make informal complaints and action is taken to sort out their concerns. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 12 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19. The accommodation in Christian Head provides residents with a pleasant environment which is suitable to meet their needs. EVIDENCE: The home is well maintained and decorated and furnished to a high standard. Systems are in place to identify areas which need maintenance and to make sure work is carried out in a timely manner. The home was purpose built as a care home for older people and is suitable to meet the needs of the people living there. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 13 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 28, 29 and 30. The home’s recruitment, training and supervision practices ensure that residents are safe and receive a high standard of care. EVIDENCE: The home’s recruitment procedures ensure that staff are suitable to work with residents. The procedure ensures residents’ safety by taking up of references and making checks against the Criminal Record Bureau and Protection of Vulnerable Adults list. Care staff receive training and support to give them the skills to provide a high standard of care and to carry out their duties safely. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 14 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. 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 and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33 and 38. The home is well managed and residents’ rights, safety and welfare are protected. Residents know their views are listened to and they can affect how services are provided. EVIDENCE: The home has systems in place to ensure that staff are trained and carry out their duties safely. Meetings are held between residents and the home’s management team to obtain views about the home and the services provided. Changes have been made to menus and activities following feedback from residents. The home’s manager should ensure that she undertakes the Registered Manager’s Award to ensure she has up to date skills and continues to be competent to manage the home. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 15 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People 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 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 X 3 X X X X X X X STAFFING Standard No Score 27 X 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 3 X X X X 3 Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 16 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action 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 OP31 Good Practice Recommendations The manager should undertake the Registered Manager’s Award. Christian Head DS0000034975.V253518.R01.S.doc Version 5.0 Page 17 Commission for Social Care Inspection Eamont House Penrith 40 Business Park Gillan Way Penrith Cumbria CA11 9BP National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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