Inspection on 14/11/06 for Church Court Care Centre

This inspection was carried out on 14th November 2006.

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

Church Court Care Centre 07/01/08

Church Court Care Centre 13/03/06

Church Court Care Centre 12/09/05

Church Court Care Centre 11/02/05

Church Court Care Centre 31/08/04

Church Court Care Centre 02/03/04

Similar services:

Fairfields Country Rest Home

Poldhu

Queensmount

Trevaylor Manor

Didsbury Court Rest Home

Belma

Hunters Care Centre

Manor Lodge

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

CARE HOMES FOR OLDER PEOPLE Church Court Care Centre Church Street Stroud Glos GL5 1JL Lead Inspector Mr Adam Parker Key Unannounced Inspection 14th November 2006 09:30 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 Church Court Care Centre DS0000016409.V313538.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. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church Court Care Centre Address Church Street Stroud Glos GL5 1JL 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) 01453 762293 01453 753161 Mrs Sally Roberts Mr Jeremy Walsh Mrs Rita June Poole Care Home 16 Category(ies) of Old age, not falling within any other category registration, with number (16) of places Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 13th March 2006 Brief Description of the Service: Church Court is a Grade II listed building dating back to the 17th Century. It is situated next to the parish church in the centre of Stroud and is within easy reach of the shops and local amenities. The home is part of the Blanchworth Care Group. Church Court is registered to provide personal care for eighteen people over the age of 65 years. Care is offered on a long or short-term basis, and nursing care is accessed from community sources if needed. The accommodation is arranged on three floors, all of which can be accessed by a shaft lift. The communal areas consist of two lounge areas and a dining area in the conservatory. There is one double bedroom with en-suite. There are also twelve single bedrooms, nine of which are en-suite. There is a well tended, attractive garden which is easily accessible to the residents. Current fees are £390.25 to £530.00. Hairdressing, chiropody, escort and personal toiletries are charged extra. The home makes information about the service, including CSCI reports available to service users through a service user guide and statement of purpose available in the home. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection visit was carried out by one inspector on one day in November 2006. The registered manager of the home was present for the inspection visit,which consisted of a tour of the premises and examination of service users care files. In addition staff recruitment and training was looked at as well as documents relating to the management and safe running of the home. A number of service users were selected for inspection against a number of outcome areas as a ‘case tracking’ exercise. Three service users were spoken to during the inspection visit. A number of comment cards were received from service users, their relatives, a General Practitioner (GP) and staff working in the home. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes into account the views and experiences of people using the service. What the service does well: The home has been well managed to provide good outcomes for service users. Systems are in place for assessing service users needs and planning care with their involvement. Care is delivered in such a way as to uphold service users privacy and dignity. Service users benefit from a range of activities provided in the home and there are links with the local church which some service users are involved in. The home was generally well maintained and clean providing service users with a safe and comfortable environment. The home has robust recruitment procedures and has a programme for providing induction and ongoing training to staff. A high percentage of staff have achieved an NVQ. The home conducts an annual quality assurance survey and in 2005 it achieved the Investors in People award for management and staff training. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: 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. Church Court Care Centre DS0000016409.V313538.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 Church Court Care Centre DS0000016409.V313538.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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home’s admission procedure ensures that all service users are admitted to the home on the basis of a full assessment of their needs, so that they can receive the care that they require. EVIDENCE: The assessment documentation for two service users recently admitted to the home was looked at. These had been completed following an assessment of the service user’s needs by the registered manager prior to admission to the home. In addition copies of needs assessments carried out by the funding authority had been obtained. The registered manager gave an example where a potential service user had been referred to the home and had not been admitted due to needs that the home did not feel it could meet. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 9 The home does not provide intermediate care and so Standard 6 does not apply. Church Court Care Centre DS0000016409.V313538.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 at least once during a 12 month period. 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 the service. Individualised care plans written with service users agreement provide staff with the information needed to meet service users’ needs. The home meets service users’ health needs through good liaison between the staff and health care professionals. Medication administration practices in the home ensure that service users are protected although storage temperatures should be monitored. Care is given in such a way as to promote the privacy and dignity of service users. EVIDENCE: Service users had care plans for a variety of needs. In some cases these were linked directly with risk assessments, for example one service user had been assessed as being nutritionally at risk and had a care plan to address this. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 11 Care plans were individualised and contained specific and clear instructions to direct staff to meet service users’ needs. In addition there was evidence that service users had been consulted about their care plans and had signed them to indicate their agreement. There was evidence of the monthly review of care plans. The home was working in conjunction with health care professionals to meet service users’ health needs. This was evident through a care plan for one service user where the involvement of community nurses had been documented in the evaluation of a wound care plan. As well as the care plan there was a wound evaluation chart and a body chart completed for this service user. Another service user’s mental health needs were being addressed through an appropriate care plan which recorded links with mental health services. Medication administration and storage arrangements were looked at. Storage was secure although storage temperatures had not been monitored and recorded. A refrigerator was available and storage temperatures for this had been monitored and recorded and were all within the correct range. Administration records were in good order with refusals appropriately recorded. Hand written entries signed and dated and in some cases counter signed by another member of staff. It was noted that liquid medication stored in bottles was dated on opening. All staff administering medication had received training with some having undergone an accredited course in the safe handling of medicines. The supplying pharmacist visits the home to carry out an inspection every three months and the registered manager was expecting a visit in the near future. Staff were observed to treat service users in a manner that respected their dignity. Service users spoken to confirmed that staff knocked on doors before entering bedrooms. The shared bedroom had curtains fitted between the two areas used by the respective service users to aid privacy. Church Court Care Centre DS0000016409.V313538.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 at least once during a 12 month period. 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 the service. Service users have regular opportunities for social stimulation through their visitors and through activities arranged by the home. Service users are able to benefit from maintaining some control and choice over their lives within the limits of their abilities. Service users’ dietary needs are well catered for taking into account individual choices. EVIDENCE: The home has an activities schedule that was posted on a notice board in the main lounge. Among the activities on offer during the week were singing and skittles. Photographs displayed on the notice board gave evidence of past activities such as arts and crafts and music and movement. The registered manager described how the activities programme had been adjusted to meet service users’ preferences. A visiting musical entertainer visits the home and service users had also experienced cheese tasting and real ale tasting sessions. A log of participation in activities is kept for each service user. Seasonal festivals such as Easter and Christmas are celebrated in the home. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 13 The home is situated next door to an Anglican Church and service users are able to visit this at times for services as well as receiving Holy Communion in the home once a month. A weekly visit is made from a Roman Catholic Priest to a number of service users in the home. The home operates an open visiting policy with service users able to receive visitors in both their own and communal rooms, a visitor was seen visiting a service user in their room during the morning. In the entrance of the home, a notice board gives information about the home, some of which may be useful to relatives or friends of service users visiting the home. The home helps service users to exercise some choice and control over their lives. During the tour of the premises, examples were seen of service users personalising their own rooms with their personal possessions including furniture. The home has information available on how to contact advocacy services for service users if these are needed. Service users can have access to their personal records held by the home if they wish. At the time of the inspection there were no service users in the home handling their own financial affairs. Lunch was served to service users in a variety of settings in the home with some taking meals in their rooms, some at tables in the lounge and seven service users sitting at tables in the dining area. Staff were serving food wearing appropriate aprons and were attentive to service users needs in one case asking them if they would like more gravy with the meal. Tables were laid with table clothes in an attractive manner. One service user described the food as “very good” and also stated that she received a “well balanced diet”. Another service user gave an example of how he had asked for and was given a choice of eggs instead of fish on one day, other service users had also opted for this choice. A record of alternative meals provided to service users was seen. Church Court Care Centre DS0000016409.V313538.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 inspected at least once during a 12 month period. 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 the service. The home has a clear complaints procedure and provides service users with opportunities to air concerns. The homes has policies and procedures which linked with staff training should ensure that service users are protected from abuse. EVIDENCE: The home has a complaints policy available in the service users guide and displayed on the notice board in the entrance of the home. The home keeps a log for recording complaints although none had been received by the home in recent times. Six survey forms were received back from relatives of service users out of these four indicated that they were aware of the home’s complaints procedure. The home has robust procedures for responding to suspicion or evidence of abuse. In addition staff receive training on abuse and challenging behaviour on a biannual mandatory basis. Five survey forms were received from staff working in the home and all of these indicated that the staff were aware of adult protection procedures. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 15 Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 16 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 & 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. Service users have the benefit of living in a generally well maintained and clean, environment. EVIDENCE: On arrival in the home it was noted that the lift was out of order however this was being worked on and was back in operation before the end of the inspection visit. Some service users had stayed in their rooms during the morning but this apparently did not have any adverse effect on them. A tour of the premises was undertaken and the home was found to be clean and generally well maintained. Comments in service users’ surveys stated that the home was either always or usually fresh and clean and one service user commented that “My room is like home from home , the way I like it.” The home has been redecorated since the previous inspection. In one bedroom the sealant around the tiles on the washbasin needed some attention before this deteriorated further. In one bedroom there was an odour. The registered Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 17 manager was aware of this and the need to replace the flooring with a more suitable material. The home has a small garden outside of the main entrance to the home which may be enjoyed by service users when the weather allows. In addition there is another area outside of the conservatory where service users may sit. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 18 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): 27,28,29 & 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The numbers of care staff ensure that service users needs are met. The level of NVQ training should ensure that service users are in safe hands. Service users are protected through robust recruitment procedures. Induction and foundation training should ensure that staff are trained and competent to meet service users’ needs. EVIDENCE: On the day of the inspection visit the home was staffed by the registered manager, two care staff, a cook and two general assistants doing cleaning and kitchen duties. The home has a system for working out the numbers of staff needed in the home based on service users numbers and their needs. Out of six survey forms received from relatives of service users, five thought that there were always sufficient numbers of staff on duty in the home. The commission has received no notifications of the home working short of staff in the last twelve months. Out of 12 care staff employed in the home,9 have a qualification at NVQ level 2 or above giving the home a ration of 75 of care staff trained. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 19 The records for the most recently recruited member of staff were examined. All the required information and documentation had been obtained with all required checks made with any risk assessments completed where necessary. Staff are provided with induction and foundation training in line with national specifications. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 20 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): 31,33,35 & 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to the service. The home is well managed with quality assurance systems and staff supervision in operation to ensure that the home is run in the interests of service users. The home has arrangements for ensuring that service users’ financial interests are safeguarded. Safe working practices ensure service users safety. EVIDENCE: Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 21 The registered manager has been in post for five years and has achieved the NVQ level 4 in care and the registered manager’s award. She has recently undergone training in food hygiene and first aid. The home conducts an annual quality assurance survey of service users and their representatives. This had taken place in June 2006 and out of 14 responses there were none that indicated any areas of the service that were in need of attention. Letters were seen from relatives and from a prospective service user visiting the home that gave positive comments. In addition the home had gained an investors in people award in 2005 in relation to its management and staff training. It is the only home in the group to have achieved this award which lasts for three years. Monthly unannounced visits are made to the home by a representative of the provider and reports are produced which are sent to the Commission. The home provides secure facilities for storing service user’s money and valuables both centrally and with locked drawers in bedrooms. Records associated with the storage of two service users money were examined and found to be accurate and in good order. Staff supervision records were examined; given the present rate of sessions the home would be on course to achieve six supervision sessions for each member of staff within a year. Staff in the home have been attending training in safe working practices in such areas as infection control, food hygiene and first aid. The home has ensured the servicing and maintenance of electrical systems and appliances as well as hoists and the lift. A new central heating boiler has recently been installed in the home. Regular checks are made on hot water temperatures and recorded along with a number of other safety checks. Work was carried out in 2005 regarding the risk of Legionella in the home. Fire drills have been held in the home including those for the night staff, two drills had been recorded for the month of November. It was noted during the tour of the premises that all bottles of cleaning materials in use on the cleaners trolley were appropriately labelled as to their contents. Church Court Care Centre DS0000016409.V313538.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 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 X X 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 X X X X X X 2 STAFFING Standard No Score 27 3 28 4 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 4 X 3 2 X 3 Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 23 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 OP26 Regulation 16 (2)(k) Requirement The registered person must take action to eliminate the odour in the bedroom identified. Timescale for action 28/02/07 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. 2. 3. Refer to Standard OP9 OP19 OP36 Good Practice Recommendations The temperature of the medication storage in the office should be monitored and recorded. The sealant around the tiles on the wash basin in Room 6 should be attended to before there is further deterioration. Continue with the present rate of staff supervision sessions to achieve six sessions per year for care staff. Church Court Care Centre DS0000016409.V313538.R01.S.doc Version 5.2 Page 24 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB National Enquiry Line: 0845 015 0120 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 Church Court Care Centre DS0000016409.V313538.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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