Inspection on 07/01/08 for Church Court Care Centre

This inspection was carried out on 7th January 2008.

CSCI found this care home to be providing an Adequate service.

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 14/11/06

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 Sharon Hayward-Wright Key Unannounced Inspection 10:40 7 & 8th January 2008 th 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.V348269.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.V348269.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 Anne Manby 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.V348269.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 14th November 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 sixteen older people. 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 a lounge, a dining area and 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 accessible to the people who use the service. 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 people through a Service User Guide and Statement of Purpose available in the home. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means the people who use this service experience adequate quality outcomes. One Inspector carried out this inspection over two days in January 2008. The judgements contained in this report have been made from evidence gathered during the inspection, which included a visit to the service and takes in to account the views and experiences of people using the service. The deputy manager was available during the inspection as were other members of the homes team. A total of 26 standards were inspected. Where possible, people living at the home were spoken with to ascertain their views on the care and services provided. Surveys were sent to the home for people who use the service and their relatives/representatives prior to the inspection to obtain their views. Surveys were also sent to the home for staff to complete. We received four surveys from people who use the service, one staff survey and seven relative/representative surveys. Visitors to the home were spoken with during the inspection. The comments received from speaking to people during the inspection and the surveys have been used in the report. The care staff were spoken with throughout the inspection and were helpful and co-operative. What the service does well: The home has a number of staff that have worked there for a long time resulting in continuity of care for people who use the service. A high percentage of the care staff have achieved an NVQ qualification. People who use the service felt that the standard of food provided is good and the cook is able to make changes to the menu based on the likes and dislikes of the people in the home. The care plans examined for two people were all personalised and had evidence that the person had been involved in the process. In places care plans had been linked to risk assessments, which is good practice. Church Court Care Centre DS0000016409.V348269.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. The summary of this inspection report can be made available in other formats on request. Church Court Care Centre DS0000016409.V348269.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.V348269.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): 3&6 People who use the service experience good quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home has admission procedures in place to ensure that all people are admitted to the home on the basis of a full assessment of their needs. EVIDENCE: The pre admission assessment of a recently admitted person was examined. The Registered Manager had completed the assessment at the home with the person present and a relative. This was completed prior to the person moving into the home. An enquiry form had also been completed. Copies of the care plans completed by Community and Adult Care Directorate (CACD) were available as well as hospital discharge information. The letter confirming the home is able to meet their needs, terms and condition and contract are sent from Blanchworth Care Group head office, and therefore this was not examined at this inspection. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 9 This person was not spoken to during the inspection but other people were in relation to how they came to move into the home. Two people said their families had chosen the home for them, as they were unable to view homes themselves. Both said they were happy with the choice their families had made. Standard 6 does not apply, as the home does not provide intermediate care. Church Court Care Centre DS0000016409.V348269.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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The health and personal care that people receive is based on their individual needs, however poor medication practices place people who use the service at risk. The principles of respect, dignity and privacy are put into practice. EVIDENCE: The outcome group for this set of standards has been assessed as ‘adequate’, however serious concerns have been highlighted with medication that need urgent attention. The care of two people was examined in detail, which included reading care records, speaking to staff and the person where they are able. Both people had been living at the home for several years. Both had assessments of needs in place but these not had been signed or in the case of one dated. It is good Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 11 practice to sign and date assessments as it demonstrates when reviews have taken place. Both people had care plans in place that were personalised and some were linked with risk assessments, which is good practice. Reviews were seen and both people had signed their care records as an indication they were involved in the process. Risk assessments were in place for pressure sores, falls, nutrition, mouth care and moving and handling. One person had a written risk assessment that had evidence of review but the last one was dated April 2007. A member of staff spoken with said they are reviewed if a change in condition takes place, however this persons condition is stable. From discussions with one of these people and a member of staff the procedure they are using for assisting both these people to use the toilet is not a recognised safe practice, however one person felt very safe with this method. A detailed risk assessment for both people is required to ensure that the safety of both the people and staff is not compromised. Records were maintained of health professional visits. An Occupational Therapist was visiting another person in the home during the inspection. Both people said they were very happy with the care they receive. In the surveys we (The Commission) received back from people who use the service; they were asked if they receive the care and support they need, all four people said ‘always’. One person had made a comment that “they have to wait for attention with the hoist” which they said they understood why. All four people said they ‘always’ receive the medical support they need. Relatives/friends were asked in their survey if they felt the care home meets the needs of their relative/friend, two said ‘always’ and five said ‘usually’. The medication systems used by the home were examined. The day before the inspection a medication administration error took place; this resulted in a member of staff administering the wrong medication to a person and the other person not receiving their medication because of this. An incident form was completed. Staff had contacted on the on-call GP and had documented his instructions and contacted the relative of the person who was given the wrong medication. The relative confirmed this. The incident form does not however include details of how this happened. The home will need to complete an investigation into how the medication error occurred to ensure steps are put into place to prevent this from happening again. Records were seen for medications received into the home and any that have to be returned to the pharmacy. All Medication Administration Records (MAR) were examined. All had a front sheet with a photograph except for two people and their name. At the top of all the MAR it was written ‘checked against previous MAR’. This is good practice, as it will help the staff to identify if any errors are present for people who are on a stable medication regime. A number of gaps were identified in the recording of administration of medication for six people. Staff must ensure that they sign when medication Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 12 has be given. Not all hand written entries were checked and signed by a second member of staff, which is good practice. The medication trolley is secured to the wall opposite the lift in the lounge and it can also be stored securely by office. It is good practice to check that the medication is stored at manufactures guidelines as at times when the conservatory door is open this leads to a change in temperature in the room where this trolley is stored. Records should be maintained of the temperature checks undertaken. Dates of opening were seen on medications that were not in the dosette system and liquid medications. However on checking the eye drops that were in use it was noticed that these were opened on the 27th November 2007 and the instructions state must only be used for 28 days, but these were still being used on the 7th January 2008. This is poor practice. The deputy manager changed the eye drops during the inspection. Parts of the medication round were observed during both days of the inspection and one member of staff took the medication out of the packing into their hand, this is an infection control risk and places the member of staff at risk of absorbing some of the medication. When staff were dispensing from the dosette system this was put straight into a medication pot. One member of staff was observed taking medication in a pot into the lift and up to the person. This is not best practice as staff could administer medication to the wrong person as what happened the day before the start of the inspection. Best practice is to take the medication in secure facility with the Medication Administration Records to the person. One person who had their care examined in detail had been administering their own cough mixture, however this was now out of date. No records were seen of this and staff would need to ensure that no interactions were taking place with any prescribed medication they were taking. This was also left on the side in their room and not stored in a lockable facility. This person was also having cream applied to their legs and the instructions from the Community nurse were written in their care plan. This said to be administered for five days from 31st December 2007. It appears it was still being used on the 8th January 2008, which is more that the five days as per instructions. Again this is poor practice and staff must follow the instructions given by health professionals. The home has an up to date medication reference book and an initials list of staff that administer medication. The deputy manager said copies of the medication administration policy and procedure are on their computer and they can print one off if staff request it. Staff who administer medication said they have done training with Blanchworth Care Group and some have done external courses in safe handling of medications. People who use the service who were spoken with said the staff respects their privacy and dignity. It was observed that one member of staff came into one persons room without knocking, which is not good practice, however it may have been they knocked the door very quickly but they came into the room at Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 13 a high speed with a meal for the person. Staff need to ensure that people can hear them knocking on the door and where able should wait for an answer. One person said they have their own telephone, which enables them to keep in contact with their family and friends. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 14 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service are able to make choices about their daily life, however the lack of a structured activities programme means that people’s recreational interests are not being met. EVIDENCE: During the inspection no activities were seen to be taking place. One member of staff was observed helping one person to look at a magazine. No activity posters were seen on the notice boards as at other homes managed by Blanchworth Care Group. Care staff said they provide activities during the afternoon hours when they are able. Some people said they were happy to make their own activities where as other people said they would like to have some provided. Several people who spend the majority of time in their room said they would like it if the care staff were able to spend time with them other than assisting them with personal care tasks but said that the staff are too busy. Staff said that at times it is difficult to undertake group activities, as people do not wish to join in. The deputy manager said an outing was arranged with another home within the Blanchworth Care Group last year but Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 15 on the day no one wanted to go. The home is very close to a local town and several people said they would like to go into town on occasions but they would need the staff or relative/friend to take them. One person said they used to enjoy ‘music and movement’ classes but these have not taken place for a while and they were not sure why. A member of staff also said they used to take place but again were not sure why they had stopped. People were asked in their surveys if they the home arranges activities they can take part in, one said ‘always’ and three said ‘usually’. Comments received on surveys from relatives said “no mental stimulation, outings, craft activities or discussions”. The homes Annual Quality Assurance Assessment (AQAA) states that this is an area the home wish to improve on by arranging more activities for people. The AQAA states that activities plans are in place for people, however out of the two people who had their care looked at in detail only one had an activities plan and the activities records kept by the home had not been written in since August 2007. The hairdresser was visiting the home on the first day of the inspection and people said they enjoy having their hair done. Peoples spiritual needs were not followed up at this inspection. Visiting to the home is not restricted and a number of people were seen visiting people at the home. One person went out to an appointment during the inspection and one person said they were able to get a taxi recently down into the local town, which they enjoyed. One person was able to discuss their financial arrangements and they said a member of their family looks after this for them. The homes AQAA states that no one from Blanchworth Care Group is an appointee for anyone at the home. Advocacy information is available at the home. People are able to bring in their own personal possessions and these were on display. People said they are able to make choices about their daily life and this includes where they eat their meals and where they wish to spend their time each day. Copies of the menus are displayed on the notice board, however both days the home had made changes to the planned menu and these were written on to the menu. From discussions with the cook the home will make changes to the menu if the people in the home do not like what is planned. The home has received ‘4-stars’ from the local Environmental Health Department. Health and safety checks are taking place as records were seen of these. Food records need to have more detail included for example, soup type and sandwich fillings. People spoken with during the inspection all said they enjoy the food provided and people were asked the same question in their surveys and two people said ‘always’ and two people said ‘usually’. A comment was received in a survey from a relative that said the home “needs to have more fresh fruit and salads as too many shop-brought sugary desserts”. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 16 One person said they are not offered a choice at the main mealtime but alternatives are provided if they do not like what is offered. The cook said they are able to cater for therapeutic diets. Another relative had commented that their relative “was missing out on certain food and that the home should give a menu with choices of dishes or ask what they would like to have for each meal”. A mealtime was observed and it was found to be a social event with alcohol offered to people who are able to have it and tables all laid with table clothes. People said they are able to choose where they eat their meals, as some people like to stay in their rooms. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 17 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service and their representatives have access to a complaints procedure and the home has some systems in place to protect people from possible risk of harm and abuse. EVIDENCE: The home has received one complaint since the last inspection and the records relating to this were examined. The home had a copy of the proposed response but an actual copy of the letter sent to the complainant was not available. A copy must be stored at the home. A copy of the complaint procedure is on the main notice board. People spoken to at the inspection said they would talk to the staff or the Registered Manager if they had any concerns. People were asked in their surveys if they know how to make a complaint and all four said ‘yes’. Relatives of people in the home were also asked in their surveys if they know how to make a complaint and six said ‘yes’ and one said ‘no’, however they said they would find out if they needed to make a complaint. Relatives were also asked if they felt the service had responded appropriately to concerns raised and four said ‘always’ and two said ‘usually’. One relative had Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 18 commented, “There have been a few improvements as a result of comments we have made and also as a result of speaking to Social Services”. From reviewing the training matrix all staff have had abuse training since 2005 provided by Blanchworth Care Group and the deputy manager said several members of staff have undertaken training by an outside provider but were unable to remember who it was. The home should consider sending staff on the ‘Alerters’ guide training provided by the local council. The deputy manager said all staff received a copy of the company’s policy on abuse at their training, as copies in the home are stored on the computer with only the Registered Manager and deputy manager having access. Blanchworth Care Group have other polices and procedures available in relation to the protection of vulnerable adults including whistle blowing. The deputy manager was not sure if the home has copies of the ‘Alerters’ guide, which is guidance about how to report any suspicions of abuse within Gloucestershire. If not the home should consider obtaining copies. In the staff survey it asked if the staff are aware of adult protection procedures and on the one survey returned they had put ‘yes’. The deputy manager said no staff have been referred to the POVA list. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 19 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, 21, 22, 24 & 26 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. People who use the service live in a generally well-maintained and clean, environment. However the physical design of the building does not always meet the needs of some people who live there. EVIDENCE: A tour of parts of the environment took place, which included viewing some rooms belonging to people who use the service. The home is a grade II listed building. The home was found to be cleaned and generally well maintained. A few areas were found that require attention and these are: • The bathroom by room 7, the bath is very stained and the side of the bath has a crack in it and must be replaced for the safety of people who use it. There was also a chair that had a cloth covering to the seat area, Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 20 which was very stained and unsightly and must be replaced. A commode bowl was being stored on the chair hoist, which is an infection control risk. • The bathroom on the top floor where the parker bath is also had two seats that have a cloth covering and again both were heavily stained. This bathroom was also being used for storage of seat cushions, which makes it look unsightly. • The window on one of the stairwells has paint that is peeling off and possible cracks were seen. • One wall in the dining room has a large crack in it. • Lighting strips are being stored in the dining area, which is safety risk to people and makes the room look unsightly. • A ladder is being stored under an eves on the top floor near to the bathroom with the parker bath and must be removed. The outside grounds were only seen from the window due to the weather but they looked very attractive and people who use the service said they would like to go outside when the weather is better. People are able to bring in items of furniture with them and these were seen in a number of rooms. People spoken with all said they like their rooms. Two people had specialist equipment provided to meet their needs. One person had bedsides in place and ‘bumpers’, however these were very stained and need to be cleaned. Two people who were spoken with are not able to have baths due to the aids they require and the layout of the bathrooms. Both people also have en-suite facilities but again they are unable to use them one because of the design and one had a step up and it is too narrow to fit any aids into. The homes AQAA states that they have received a grant to provide a memory room at the home. People were asked during the inspection if they were happy with the cleanliness of the home and they all said yes. People were also asked the same question in their survey and again all four people said ‘yes’. No odours were found during the tour of parts of the home. One minor cleanliness issues was identified on both days of the inspection but was rectified on the second day. Staff were observed wearing protective clothing, and gloves and aprons were available around the home. The home now has a specialist contract in place for disposal of incontinence pads and the domestic was knowledgeable about the policy for this. The laundry area was inspected and the laundry assistant said they have a procedure in place for managing soiled linen. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 21 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 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. The home does not have sufficient numbers of staff on duty to ensure that people who use the service have all their needs met. An ongoing training programme is available for staff to attend. EVIDENCE: From discussion with the deputy manager staffing numbers have altered since the last inspection. They now have only two care staff on duty for each shift and duty rotas confirmed this. However on the second day of the inspection the home had three care staff on duty. People who use the service who were spoken with said they have to wait for care staff to attend to them especially if they require two staff for hoisting. People who use the service and comments received on relatives’ surveys also said that activities are not always taking place and care staff confirmed this, as at times they are too busy assisting people with personal care. At the time of the inspection the deputy manager said about five people need hoisting. Care staff said that they do not always have enough time to take their breaks as there is only of two of them and they have to take a break when they can. A complaint was received by the home last November that mentions the care staff not being available in the home when a person was calling for assistance. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 22 The care staff also has to undertake other tasks, including some preparation of the evening meal, serving people and laundry duties after 4pm and at weekends. This will also impact on the time care staff have to provide activities for people. The member of staff that completed the staff survey also said that more care staff are needed. Ancillary staff are available to assist the care staff. People were asked in their survey if they receive the care and support they need and two said ‘always’ and one said ‘usually’. A comment was made “apart from a wait for attention with the hoist”. They were also asked if the staff were available when they needed them, two people said ‘always’ and one person said ‘usually’. Relatives were asked in their surveys if the home gives the care or support that they expect to their relative, three said ‘always’ and three said ‘usually’. People spoken to during the inspection all praised the care staff saying they were hard working and very helpful. One person mentioned an incident that involved an ancillary member of staff and this was relayed to the Assistant Director of Care via the telephone. Comments received from relatives’ surveys include, “staff are very caring towards my mother and myself and nothing is too much trouble” and “some of the staff have been very abrupt in manner and there is an oppressive atmosphere but this is starting to improve”. A number of staff have been working at the home for a long time which provides continuity for people who use the service. The homes Annual Quality Assurance Assessments (AQAA) states that all but one member of care staff have an NVQ 2. One of the domestic assistants said they are also undertaking an NVQ in cleaning. The deputy manager said the home has not had any new staff since the last inspection but has had staff transferred from a sister home. On the second day of the inspection the home had a work experience person working at the home. The care staff said they were not undertaking any personal care for people who use the service. The Assistant Director of Care was asked to provide evidence that a Criminal Records Bureau Disclosure had been obtained and a POVA check. Blanchworth Care Group said that they were under the impression that the college would undertake these checks and they were also not informed when they are starting at the home. They have now told the college that the work experience people will not be able to start at the home until the required checks are in place. Whilst the company have now taken the appropriate action in stopping them from working in the home, they need to obtain evidence from the college that these checks have taken place. The home does not have any staff undertaking an induction programme at the time of the inspection. The home would follow Blanchworth Care Group booklets and attend the training provided by them. The deputy manager had a copy of an up to date training matrix for all staff in the home. There were a number of gaps where training needed to be updated. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 23 Once the Registered Manager returns from holiday this will need to be addressed. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 24 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 & 38 People who use the service experience adequate quality outcomes in this area. This judgement has been made using available evidence including a visit to this service. An experienced person directs the management and administration of the home, however the home is not always run in the best interests of the people who use the service. EVIDENCE: There have been no changes to the management of the home since the last inspection. The Registered Manager was on annual leave during both days of the inspection and the deputy manager was able to be present for the first day. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 25 Since the last inspection there has been a decline in the standard of the service provided by the home. This includes the poor medication practices, lack of staff supervision and the lack of activities and stimulation provided for people who use the service. The home was not able to demonstrate at the time of the inspection whether safe recruitment practices are in place for the person that is undertaking work experience. The homes quality assurance systems were examined. In June 2007 the home sent out questionnaires to people who use the service and their relatives. Results of these were displayed in the home. Regulation 26 visits are taking place and copies of the reports were seen at the home. Some of these included audits of care plans, medication, kitchen and laundry and checks on rooms in the home. Auditing of accidents takes place monthly as records were seen of these. The deputy manager was not aware if the Registered Manager undertakes any auditing of the home herself. The home manages monies for a number of people who use the service. Secure facilities are provided. Records and receipts are kept. Two were randomly selected and the records and monies held all tallied. The deputy manager said that the Registered Manager undertakes supervision on all staff in the home. Records relating to staff supervision were examined. Each member of staff completes a front sheet then both the Registered Manager and member of staff sign the sheet. On examination of records the last recorded session for care staff was July 2007. The staff survey asked if they received formal one to one supervision and they had answered ‘no’. The home must improve on this to meet the recommended six times per year. The homes AQAA states that all care staff receive formal supervision and a minimum of six times per year supervision. The deputy manager said that staff appraisals are now due. The AQAA contains details of servicing of equipment to include electrical circuits and the heating system. Records were seen for weekly fire equipment checks on lighting and alarms. Other checks seen include fire doors, routes and fire fighting equipment for examples extinguisher and fire blankets. The deputy manager was not able to find records of any fire training for staff or drills. The deputy manager was also not able to find a copy of the homes fire risk assessment. Monthly water temperature checks are being undertaken. One of the wheelchairs being used by a person needed to be cleaned and the armrest changed as they were damaged leaving the foam exposed. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 26 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 2 9 1 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 2 X 2 3 X 3 X 2 STAFFING Standard No Score 27 1 28 4 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 1 X 2 Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 27 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 OP8 Regulation 13 (4c) Requirement The two people identified at this inspection must have their moving and handling practice risk assessed to ensure it does not place the people and staff at unnecessary risk. The home must not administer prescribed medication to people that is passed the manufactures guidelines as this places them at risk. The procedure used for administering medication in the home must be reviewed to ensure people are not placed at risk. A risk assessment must be completed to demonstrate this has taken place. A full investigation must be undertaken into the medication error that took place on the 06/01/08 and a copy of the investigation and findings sent to us (The Commission). Detailed records of all medication administered to people who use the service must be kept. This will help to ensure that people receive the correct DS0000016409.V348269.R01.S.doc Timescale for action 15/02/08 2 OP9 13(2) 08/01/08 3 OP9 13(2) 15/02/08 4 OP9 13(2) 15/02/08 5 OP9 Sch 3 (3i) 15/02/08 Church Court Care Centre Version 5.2 Page 28 6. OP12 16(n) 7. OP16 17 (2) (3b) 8. OP19 23(2b) 9. OP26 16(k) 10. OP27 18(1a) 11. OP29 Sch 2 (7) 12. OP36 18(2a) levels of medication. The home needs to provide a range of activities for people who use the service following consultation with them to ensure they meet their needs. Copies of all correspondence sent to the complainant must be stored in the home and be available for inspection at any time. This is to ensure that views of people who use the service are listened to and action put in place to address them. The home must address the maintenance issues identified in the Environmental Standards to ensure people who use the service are not put at unnecessary risk. The home must address the infection control and cleanliness issues identified in the Environmental Standards to ensure people who use the service live in a clean and pleasing environment. The home must review their staffing levels to ensure that not just the personal care needs of people who use the service are being met but their social and recreational needs. This will ensure that people who use the service are able to chose and enjoy their lifestyle. The home must provide evidence to us (The Commission) that the person undertaking work experience has had a Criminal Records Bureau Disclosure and POVA check prior to working at the home. This is to ensure that people who use the service are not being put at unnecessary risk. The home must ensure that all staff are appropriately DS0000016409.V348269.R01.S.doc 29/02/08 15/02/08 30/03/08 28/02/08 29/02/08 15/02/08 29/02/08 Page 29 Church Court Care Centre Version 5.2 supervised to ensure the needs of the people who use the service are being met. 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. 4. 5. 6. 7. Refer to Standard OP9 OP9 OP9 OP15 OP18 OP18 OP36 Good Practice Recommendations The temperature of the medication storage in the office should be monitored and recorded. The temperature of the medication stored in the trolley in the main lounge should be monitored and recorded to ensure it is stored as per manufactures instructions. Handwritten entries on Medication Administration Records should be checked and signed by a second member of staff to reduce any errors. More detail is needed with food records to ensure sandwich fillings and the type of soup offered is recorded. The home should consider sending all staff on the ‘Alerters’ guide training which is about the reporting procedures for this county. The home should obtain copies of the ‘Alerters’ guide booklet. The home should ensure that all care staff receive six supervision sessions per year. Church Court Care Centre DS0000016409.V348269.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection Gloucester Office Unit 1210 Lansdowne Court Gloucester Business Park Brockworth Gloucester, GL3 4AB 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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