Inspection on 03/01/07 for Christian Head

This inspection was carried out on 3rd January 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Christian Head 28/10/05

Christian Head 27/04/05

Christian Head 17/01/05

Christian Head 11/08/04

Christian Head 13/02/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Christian Head Silver Street Kirkby Stephen Cumbria CA17 4HA Lead Inspector Jacqueline Southern-Leigh Unannounced Inspection 3rd January 2007 09.50 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.V291176.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 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.V291176.R01.S.doc Version 5.2 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 www.cumbriacare.org.uk 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.V291176.R01.S.doc Version 5.2 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. 28th October 2005 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, however there are no residents currently sharing a room. Three bedrooms have ensuite facilities and there are appropriate toilet and bathing facilities close to all the accommodation provided for residents. Current fees for the home are between £363 and £385 per week. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced Key Inspection commencing at 9.50am and finishing at 3.00pm, the Pharmacy Inspector was also present on this occasion undertaking an in-depth assessment of the homes provision for medication, this took place between 10.45am until 2.30pm. The inspection included a tour of the premises, speaking to residents and staff and a review of the policies and procedures. The Registered Manager was not available on the day of inspection but a Supervisor Ms Gillian McGuirk was able to supply the inspection team with all the necessary information. What the service does well: What has improved since the last inspection? What they could do better: The are some issues regarding medication that need to be tightened up, in particular around the receipt of medications into the home, the use of sticky labels on the medication charts and ensuring that charts are signed correctly. Although the home appears to be following the organisation policies and procedures regarding recruitment, which are thorough, and of a good standard, it is not possible to inspect these as some of the paperwork is missing from the files kept at the home, this needs to be rectified as soon as possible. Christian Head DS0000034975.V291176.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. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 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.V291176.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3, 4, 5 & 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home ensures that it can meet the needs of prospective residents and provides them with relevant information regarding the home. EVIDENCE: New residents to the home come via a referral from Social Services; the home does not deal directly with any fees for the home this is again organised by Social Services. However, potential new residents and their families may visit the home to have a look around, they do not necessarily need an appointment. The home issues all residents with a copy of its Terms and Conditions; they are also given a copy of the Statement of Purpose for Christian Head. After the new resident has been referred to the home by Social Services the manager or a supervisor will go out and visit the person either in their home or in hospital. They will assess the needs of the person and decide whether the home can meet their current care needs and whether the person will be offered Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 9 a place at the home. This is good practice to ensure that the home is a suitable environment for the potential new resident. The new residents and their families are able to look at the room on offer and the general environment of the home and decide if they would like to move in, at this stage they can also choose what furniture and personal belongings they may like to bring into the home. During the inspection one resident told me that he had been coming to the home on a regular basis over the last few years and when he decided that he needed to move into a home on a permanent basis he chose Christian Head because it was a ‘home from home’. The home does not currently offer intermediate care. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9 & 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a good assessment procedure that meets the needs of the service users and ensures that health, personal and social care is well maintained. EVIDENCE: Individual plans of care that were checked on the day of inspection were found to be comprehensive and considered all aspects of the residents lives including their health and care needs, dietary assessments and various aspects of health and safety with risk assessments. The information was up-to-date and had been reviewed on a regular basis. I was able to speak to several residents in detail, one resident told me that ‘my privacy is always respected by the staff’ and ‘they help me to stay independent’. Residents also reported that nurse call bells were answered promptly and they were not kept waiting for help. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 11 The Pharmacy Inspector looked at all issues regarding the safe handling, storage, administration and disposal of medication. The Inspector found that the homes systems and processes were adequate in some areas and good in others. Medicines were stored well so that residents received good quality treatment. Residents were able to take their own medicines if they wanted to and were appropriately supported to do so, one resident was very happy to be able to do this, he said that medicines were ordered for him and never ran out. However, records for receipt and administration of medication must be improved to ensure that residents receive the correct medicines at the intended dosage. Medicines records were signed when they were given and a record was kept of medicines that were disposed of, but records were poor for medicines received into the service. These records must be improved to show that residents’ medicines are handled properly. Records that are signed when medicines are given must also be improved to keep residents safe from errors. The service must review the use of loose medicines labels that are stuck to these records as they may be put on the wrong one and can result in residents receiving the wrong treatment. One record had a label belonging to another resident’s medicine stuck to the back of it. Some records had more than one label for the same medicine that could result in double dose. When medicines were changed the records were not always updated properly this puts residents at risk of receiving the wrong treatment. Some records did not have the full name of the medication, dosage and date and one record did not show the resident’s name. Some medicines were not recorded properly for administration and may not have been given as prescribed. For example, there were more signatures than there should have been for some courses of antibiotics. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14 & 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home supports the residents to maintain a balanced lifestyle with options for choice. EVIDENCE: The Care Staff at the home provide as many activities for the residents as they can, the home does not employ an Activities Coordinator or any staff specifically to provide recreational interests for the residents. However, the staff at the home do recognise the importance of offering the residents different social and recreational opportunities and they do make an effort to provide these within their normal working hours. At Christmas the staff at the home organised a lot of different activities and some trips for the residents, the residents appreciated this, one resident told me that they had just had a ‘smashing Christmas and New Year’. There is a religious service every Monday for any residents that wish to attend, Ministers from different religions come each week but all residents are made welcome. An organist also comes to the home on a regular basis and the residents often have a ‘sing along’. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 13 The family and friends of the residents are welcome at the home; there are no restrictions on visiting times. One resident told me about the residents meetings that are held, they were six monthly but they are increasing in frequency, the manager and a supervisor attend, the resident felt that the staff at the home took the meetings very seriously and that the residents opinions were listened to. The meals at the home are cooked freshly on a daily basis, with two/three choices offered for each meal, if residents do not like any of the choices on offer they would be given an alternative meal. The kitchen was large and well equipped, it looked clean and was well organised. Copies are kept of the resident’s meal choices to monitor dietary intake and preference. Residents told me that the food was ‘excellent’, ‘I can’t fault the food’ and ‘on the whole it is very good’. The meal observed on the day of inspection was well presented and looked appetising. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home has a complaints process that protects the rights of the residents EVIDENCE: A copy of the homes complaints procedure is given to each resident; the manager has now placed a copy in the reception area. The home follows the complaints process that is used by all Cumbria Care homes, this provides consistency across the organisation, however, the copy that was available on the day of inspection contained old information and referred to the Commission for Social Care Inspection by its old name the National Care Standards Commission, this needs to be updated. There have only been two complaints since the last inspection, these were both around environmental issues, heating and hot water and also the garden, both complaints were resolved and dealt with by the manager within a few days. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 15 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. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The environment of the home is clean, warm and safe; it meets the needs of its residents. EVIDENCE: The home has facilities for thirty-three residents, however, two of the bedrooms are kept on a permanent basis as short-term respite beds, they can be accessed via Social Services who will liaise with the home. The home is laid out over two floors; there is a lift for access. The bedrooms are split into four units; each unit has its own lounge with a galley kitchen for making drinks for the residents. There are four bathrooms, two upstairs and two downstairs; there is also a shower room available. The bathrooms were all in good repair and decoration; the temperature was good in all the bathrooms on the day of inspection. Each bathroom has a hoist; there are also other hoists for use around the home. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 16 There are nine separate toilets around the home in various locations; each bedroom has a toilet nearby. The bedrooms are all of a reasonable size with some being larger than others, there are two rooms that are large enough to use as double rooms but they are currently occupied by one resident. The smaller bedrooms have been organised efficiently and the current residents are all happy with their rooms. All the bedrooms have a washbasin and three bedrooms have en-suite facilities. The bedrooms are all nicely decorated some with patterned wallpaper; the corridors and lounge areas are also in good decorative order. Each residents bedroom was personalised to varying degrees, residents are encouraged to bring in their own personal possessions but furniture must be fire retardant and electrical equipment must be tested before it is brought into the home. There are nice outside areas for the residents use, the home is also very close to the pleasant village of Kirkby Stephen. The home employs two cleaners who keep the home clean and tidy, there were no unpleasant odours. There is a laundry within the home; care staff are only expected to do the laundry when the laundry assistant is on days off. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 17 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. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A staff team that has been recruited, inducted and trained adequately to give a good standard of care meets the service users needs. EVIDENCE: The home employs Care Assistants and Supervisors to care for the personal and care needs of the residents, as well as catering, cleaning, laundry staff and a part time handyman. The staffing levels are adequate to care for the needs of the current residents. The home encourages the care staff to undertake National Vocational Qualifications in care, for example four out of the six night staff have this qualification. Staff all have learning contracts with Cumbria Care for continuing education. There is an induction process for new staff; this includes spending three days at Petril House in Carlisle covering issues such as manual handling, emergency action and first aid, fire training and the organisations policies and procedures. Evidence was also seen of staff receiving manual handling up-dates and fire training. However, the Registered Manager and the Organisation must also ensure that staff receive regular up-dates on all mandatory training as well as other issues such as protection of vulnerable adults and end of life care. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 18 The home follows the organisations recruitment and selection policies, no staff are allowed to start work at the home without clearance from the central Human Resource (HR) department that ensures Criminal Record (CRB) checks are completed and two references have been received. On the day of inspection in the personnel files that were examined only one CRB form was confirmed as received and references were also missing from some of the files. The manager is pursuing this with the HR department, the information required by the Commission for Social Care Inspection as set out in the National Minimum Standard 34 should be available for inspection. The residents were very happy with the care they received, they said that the staff were ‘very patient and kind’, that the staff were ‘a great bunch’ and also that they were ‘wonderful, can’t fault anyone of the staff, they are very kind’. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 19 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. JUDGEMENT – we looked at outcomes for the following standard(s): 31,33,35,36,37 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The management of the home safeguards the rights and best interests of the residents. EVIDENCE: The Registered Manager of the home is Janet Sephton, Ms Sephton is currently undertaking the Registered Managers award, and she also holds other qualifications relevant to her role as the manager of the home. The management structure of the home also includes Supervisors; there is one supervisor on each day shift to over see the day-to-day care given to the residents. On the day of inspection Gillian McGuirk, one of the Supervisors was able to provide all the information that we required, this demonstrated that the Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 20 management team of the home work well together and that information is cascaded from the Registered Manager to the Supervisors. The residents of the home were aware of who they needed to speak to if they had any problems or concerns and were happy to go directly to Ms Sephton as they felt she was approachable. Staff supervision is undertaken on a fairly regular basis, but the manager must ensure that all care staff receive supervision at least six times a year. The home has Cumbria Care’s policies and procedures in place for all Health and Safety and Risk Assessment issues and the organisation undertakes an annual Health and Safety audit. Ms McGuirk was also able to demonstrate that the home also does monthly Health and Safety checks that looked at general maintenance issues. Information regarding the Control of Substances Hazardous to Health is kept with the relevant chemicals and staff receive training and up-dates. Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 21 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 3 3 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 3 3 3 Christian Head DS0000034975.V291176.R01.S.doc Version 5.2 Page 22 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 OP9 Regulation 13(2) Requirement The registered person must ensure that records for receipt and administration of medicines are complete and accurate. Timescale for action 01/03/07 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 2 Refer to Standard OP9 OP29 Good Practice Recommendations The home should stop the use of sticky labels on medication charts to ensure there are no medication errors if the labels become unstuck. The home should have copies of the all recruitment information which is currently kept centrally, in the files kept at the home. 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