Inspection on 12/07/05 for Church Terrace Nursing & Residential Home

This inspection was carried out on 12th July 2005.

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 Terrace Nursing &... 15/02/07

Church Terrace Nursing &... 15/02/06

Church Terrace Nursing &... 17/12/04

Church Terrace Nursing &... 30/06/04

Church Terrace Nursing &... 05/01/04

Similar services:

Coton Hill House

Doddington Lodge

Far Croft

The Lodge Nursing Home

Bracken House

Sunnycroft

Churchill House Nursing and Residential Home

Field Farm House

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

CARE HOMES FOR OLDER PEOPLE Church Terrace The Terrace Cheadle Stoke - on - Trent Staffordshire ST10 1PA Lead Inspector Pam Grace UnAnnounced 12 July 2005 2.00p.m. 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 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 Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 3 SERVICE INFORMATION Name of service Church Terrace Nursing & Residential Home Address The Terrace Cheadle Stoke-on-Trent Staffordshire ST10 1PA 01538 750736 Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Minehome Ltd Mrs Lesley Jane Hughes CRH 71 Category(ies) of DE(E)- 71 registration, with number MD- 2 of places MD(E)- 71 PD- 2 PD(E)- 1 Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 4 SERVICE INFORMATION Conditions of registration: 20 MD minimum age 50 years 20 DE minimum age 50 7 MD minimum age 35 years 2 PD & MD under 65yrs on a temporary basis and then this category will cease 1 PD(E) named male resident aged 75 years presenting mental health problems Date of last inspection 17 December 2004 Brief Description of the Service: Church Terrace is a purpose built Care Home with Nursing. The home is situated on a main road within Cheadle town and has direct access to the town shops and facilities. The home comprises of two floors, served by a passenger lift, and stands in enclosed gardens. There is a car park within the grounds of the home. The home is registered with the Commission for Social Care Inspection to accommodate up to 71 service users over the age of 65 years with varying degrees of dementia and mental disorder requiring either residential and or nursing care. There are three units within the main building offering care with nursing (mental health), and a smaller unit for service users with residential care needs (mental health). The nursing units are as follows:Maple Dene (20 service users), Autumn Leaves (21 service users), and Oaklands (15 service users). All of these units care for service users who have varying degrees of mental health nursing needs. Blossom Court is a unit dedicated to caring for up to 11 service users with mental health (residential) needs. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This statutory unannounced inspection was carried out over 9.5 hours by one inspector. A tour of the home was undertaken and discussions were held with service users, visitors and staff. Discussions were also held with the registered manager of the home. Relevant records and documentation was examined. Service users spoken with were very positive about the care they were receiving, there were also service users who were unable to communicate, the inspector noted that they appeared well cared for, and were happy in their surroundings. Conditions in the home were determined by direct observation, and sampling other services provided, such as medication, and aspects of health and safety measures. There had been 3 complaints made in the last 9 months, two were made directly to the Commission for Social Care Inspection, and one was made to the home. Recommendations have been made in relation to these at the time to ensure that standards are maintained. What the service does well: Daily routines are flexible, and individual preferences are taken into consideration. Health care awareness was evident, with the importance of any changes in health status and mental health, being continually monitored by appropriately trained, caring and diligent staff. Service users individual needs and wishes were well met, and service users were treated with dignity and respect. The manager has recently introduced an away day for all care staff. These will cover a variety of training topics for staff, and will include team - building exercises. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 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 Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 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 Standards Statutory Requirements Identified During the Inspection Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 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 standard(s) 3,4 Service users and their family/ representatives felt assured that the home would be able to meet service users’ assessed needs EVIDENCE: Each service user has an assessment of his or her needs undertaken before admission to the home. The registered manager or senior nurse usually undertakes this assessment. There was written evidence of this contained within care plans. This assessment usually involves the next of kin who provides information, which is then transferred to the plan of care. In most instances there has been an assessment by another professional such as a Social worker. Service users are informed in writing that their assessed needs will be met by the home. Service users spoken with at the time of the inspection confirmed this. There was evidence of specialist advice and treatment contained within care plans. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 Appropriate arrangements are in place for identifying and meeting the health and personal care needs of service users in the home. Service users are protected by the home’s policies and procedures for dealing with medicines. EVIDENCE: Service user care plans were sampled and examined. They evidenced that individual health, personal and social care needs had been established, and were being met. Service users and a visiting relative spoken with said they were satisfied with the care they and their relative received. There was a safe system in place for the receipt, storage, administration and disposal of medicines. Medication Administration records were checked and found to be in good order. Each service user had a photograph on their file, and all medication checked was correctly labelled and dated. Controlled Drugs were checked, and these tallied with stock levels held. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 10 There were no service users administering their own medication at the time of the inspection. The inspector noted during the inspection that service users were treated with respect and their privacy was upheld. Staff were seen to knock on service user’s bedroom doors prior to entering, and waited for consent to open the door. Some service users in the home had mental health needs, which meant that not all conversation was meaningful. However, the inspector noted how well service users appeared, and how happy the atmosphere was in the lounge areas. Staff interacted appropriately and professionally with those service users. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 11 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 standard(s) 13,14 Service users maintain contact with family, friends, their representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. EVIDENCE: There was evidence from talking to service users and a visiting relative that contact is maintained with family and friends on a regular basis. There were no restrictions placed on visiting times, and the home provides a relaxed and friendly environment. One service user who has difficulty with verbal communication gave the thumbs up sign to the inspector when asked if they were satisfied with the services they receive at the home. The inspector spoke with the activities co-ordinator. Activities were planned around individual choice and preferences. Plans are in progress regarding ideas for group activities, and during the inspection some service users went out to the cinema. The inspector noted that the hours set aside for activities at the home are flexible, to include weekends, and some evenings. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 12 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 standard(s) 16 The CSCI is satisfied that the complaints received by the home have been listened to, taken seriously, and acted upon. EVIDENCE: The Commission for Social Care Inspection had received 2 complaints in the past 9 months. The home had dealt with an additional complaint through an internal investigation. A complaint received recently by the CSCI had been investigated and partly upheld. These issues were all investigated by CSCI. The manager had taken the comments from all three complaints seriously and they had been appropriately acted upon. Service users and relatives spoken with said that they had no cause to complain at present, but commented that they would speak to the home manager or one of the nurses if they needed to. They were aware that the home has a complaints procedure. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 13 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 standard(s) 19,20,22,23,24,25,26 The location and layout of the home is suitable for its stated purpose. Service users live in a safe and comfortable environment, which has been adapted to suit their lifestyle, and individual needs. EVIDENCE: The inspector undertook a tour of the home, which included all the communal areas. The home was found to be clean and well presented throughout. Bedrooms seen were personalised, and had been adapted to suit the needs of the service users. Wardrobes were either fitted, or fixed to the wall for safety. All service users now have a lockable facility/cabinet in their bedrooms. Bedrails were used following a risk assessment. Bumpers were used with these. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 14 Various aids and adaptations were in place including assisted baths, mobile hoists and other equipment used for moving and handling of service users. There was a nurse call bell in operation, which was seen and heard to be working at the time of the inspection. The home’s refurbishment programme is still ongoing, and many areas of the home have been vastly improved with the replacement of carpets, furnishings and decorating of rooms. Blossom Court unit has yet to refurbished. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 15 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,30 Staff members are present in sufficient numbers and have the necessary skills, competencies and experience to care for the service users. Staff members are appropriately recruited to work at the home, and service users are protected by the home’s recruitment policy and practices. EVIDENCE: At the time of the inspection there was a total of 67 service users resident in the home. Duty rotas were examined. At the time of the inspection, there was one member of care staff off sick on Blossom Court unit. However, all other units were appropriately staffed. The home employs 34 care staff and 11 nursing staff. There are also 5 kitchen staff including 2 cooks, 1 maintenance person, 1 activities co-ordinator, 1 administrator, 5 housekeeper/domestic staff, and 2 laundry staff. The manager is supernumery and covers the floor on occasions. The manager confirmed that existing staff members try to cover shifts that other staff are unable to undertake, due to sickness or holidays. The home is well on it’s way to achieving 50 per cent NVQ trained staff. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 16 The inspector interviewed staff members. Staff spoken with confirmed that they had received appropriate training, this included induction, and in house training. Staff training records seen confirmed this, and also confirmed that they had received instruction on fire safety, fire drills and moving and handling training. The inspector viewed an induction programme specifically for domestic staff at the home. This was discussed with two new staff members and their supervisor. The supervisor is responsible for overseeing, and implementing the induction for new staff. The induction programme was comprehensive, and informative. A sample of staff recruitment files was examined and there was evidence of a thorough recruitment procedure including 2 written references, CRB and POVA check. All prospective employees are interviewed and employment history is obtained. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 17 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 The manager is appropriately trained and experienced to run and manage the home. Service users benefit from the way in which the home is managed, and the home is run in the best interests of the service users. Staff are appropriately supervised. EVIDENCE: The manager is very well qualified and experienced to oversee the running of the home. Her management style is open and transparent, and includes the views of staff and service users. There was evidence of regular staff supervision within staff files seen. The manager confirmed that supervision had now been regularly established for care staff. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 18 Records relating to Fire alarm testing, detecting and fire fighting equipment were up to date, and had been appropriately serviced and tested. Records relating the testing and maintaining of the emergency lighting were up to date and had been appropriately completed. Accidents had been recorded as required and audited on a regular basis. Evidence was seen of regular staff mandatory health and safety training including regular fire drills and the staff spoken to confirmed this. The manager and staff spoken with confirmed that service user meetings are being held. A certificate for legionella - compliance was viewed by the inspector. This is now due for renewal. Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 19 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 x x 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 x 13 3 14 3 15 x COMPLAINTS AND PROTECTION 3 3 x 3 3 3 3 3 STAFFING Standard No Score 27 3 28 x 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 x x 3 3 3 x x 3 x x Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 20 No Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations Church Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 21 Commission for Social Care Inspection Stafford - Dyson Court Staffordshire Technology Park Beaconside Stafford ST18 0ES 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 Terrace E51-E09 S26942 Church Terrace V236938 13.07.05 Stage 4.doc Version 1.40 Page 22 - 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. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. The policy of www.bestcarehome.co.uk is to use all legal avenues to pursue such offenders, including recovery of costs. You have been warned!