Inspection on 05/01/04 for Church Terrace Nursing & Residential Home

Care Home For Older PeopleChurch Terrace Nursing & Residential HomeThe Terrace Cheadle Stoke-on-Trent Staffordshire ST10 1PAUnannounced Inspection5 January 2004 Commission for Social Care InspectionLaunched in April 2004, the Commission for Social Care Inspection (CSCI) is the single inspectorate for social care in England. The Commission combines the work formerly done by the Social Services Inspectorate (SSI), the SSI/Audit Commission Joint Review Team and the National Care Standards Commission. The role of CSCI is to: · Promote improvement in social care · Inspect all social care - for adults and children - in the public, private and voluntary sectors · Publish annual reports to Parliament on the performance of social care and on the state of the social care market · Inspect and assess `Value for Money of council social services · Hold performance statistics on social care · Publish the `star ratings for council social services · Register and inspect services against national standards · Host the Childrens Rights Director role.Inspection Methods & FindingsSECTION B of this report summarises key findings and evidence from this inspection. The following 4-point scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The 4-point scale ranges from: 4 - Standard Exceeded (Commendable) 3 - Standard Met (No Shortfalls) 2 - Standard Almost Met (Minor Shortfalls) 1 - Standard Not Met (Major Shortfalls) O or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable. ESTABLISHMENT INFORMATION Name of establishment Church Terrace Nursing & Residential Home Address The Terrace, Cheadle, Stoke-on-Trent, Staffordshire, ST10 1PA Email Address Name of registered provider(s)/Company (if applicable) Minehome Limited Name of registered manager (if applicable) Type of registration Care Home No. of places registered (if applicable) 71 Tel No: 01538 750736 Fax No: 01538 754034Category(ies) of registration, with (number of places) Dementia - over 65 years of age (71), Mental Disorder, excluding learning disability or dementia - over 65 years of age (71) Registration number E090000065 Date First registered Date of latest registration certificate 30 July 2002 Was the home registered under the Registered Homes Act 1984 Do additional conditions of registration apply ? Date of last inspection YES If Yes Refer to Part C 5/6/03Church Terrace Nursing & Residential HomePage 1 Date of Inspection Visit Time of Inspection Visit Name of Inspector 15 January 2004 09:30 am Mrs Yvonne Allen Mr Berwyn BabbID Code075932Name of Inspector 2 Name of Specialist (e.g. Interpreter/Signer) (if applicable) Name of Establishment Representative at the time of inspectionNot applicable Lesley Hughes (acting manager) Mr Shah (proprietor)Church Terrace Nursing & Residential HomePage 2 CONTENTSIntroduction to Report and Inspection Inspection Visits Brief Description of the Services Provided Part A: Summary of Inspection Findings Inspection Summary Statutory Requirements/Good Practice Recommendations from last Inspection Conditions of Registration Statutory Requirements/ Good Practice Recommendations from this Inspection Part B: Inspection Findings National Minimum Standards For Older People: Choice of Home Health and Personal Care Daily Life and Social Activities Complaints and Protection Environment Staffing Management & Administration Part C: Part D: D.1. D.2. D.3. Compliance with additional conditions of registration (if applicable) Providers Response Providers comments Action Plan Providers Agreement Signature Mrs Yvonne Allen Second Inspector Mr Berwyn Babb Locality Manager Mr Stuart Rudd Date 19 May 2004 Public reports It should be noted that all NCSC inspection reports are public documents. Signature SignatureLead InspectorYvonne Allen Berwyn Babb Mr Stuart RuddChurch Terrace Nursing & Residential HomePage 3 INTRODUCTION TO REPORT AND INSPECTION Every establishment that falls within the jurisdiction of the National Care Standards Commission (NCSC), is subject to inspection, to establish if the establishment is meeting the National Minimum Standards relevant to that setting and the requirements of the Care Standards Act 2000. This document summarises the inspection findings of the NCSC in respect of Church Terrace Nursing & Residential Home. The inspection findings relate to the National Minimum Standards (NMS) for Care Homes for Older People published by the Secretary of State under the Care Standards Act 2000. The Regulations applicable to the inspected service are secondary legislation, with which a service provider must comply. Service providers are expected to comply fully with the National Minimum Standards. The National Minimum Standards will form the basis for judgements by the NCSC regarding registration, the imposition and variation of registration conditions and any enforcement action. The report follows the format of the NMS and the numbering shown in the report corresponds to that of the standards. The report will show the following: · Inspection methods used · Key findings and evidence · Overall ratings in relation to the standards · Compliance with the Regulations · Required actions on the part of the provider · Recommended good practice · Summary of the findings · Report of the Lay Assessor (where relevant) · Providers response and proposed action plan to address findings This report is a public document. INSPECTION VISITS Inspections are undertaken in line with the agreed regulatory framework with additional visits as required. This is in accordance with the provisions of the Care Standards Act 2000. The report is based on the findings of the specified inspection dates.Church Terrace Nursing & Residential HomePage 4 BRIEF DESCRIPTION OF THE SERVICES PROVIDED. 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 National Care Standards Commission to accommodate up to 71 service users over the age of 65yrs suffering from differing 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 separate 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 Oak lands (15 service users). All these units care for service users with 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 Nursing & Residential HomePage 5 PART A SUMMARY OF INSPECTION FINDINGSINSPECTORS SUMMARY (This is an overview of the inspectors findings, which includes good practice, quality issues, areas to be addressed or developed and any other concerns.) The inspection was carried out over one day by two inspectors on an unannounced visit. The newly appointed home manager was on duty at the time of the inspection. She was awaiting registration by the NCSC. The previous acting manager had returned to work following maternity leave as a unit manager. The proprietor was visiting the home during the day and met with the inspectors. The inspectors also met with various staff members, service users and visitors. At the end of the inspection feedback was given to the acting manager. Most of the standards assessed had either been fully or partially met. There were areas within the home and services offered which required further development and the acting manager was aware of these and had already started to make headway into these areas at the time of the visit. The service users and visiting relatives were complimentary about the care received and the staff that worked there stated that they felt supported and happy in their job roles. Choice Of Home ­ Standards 1-6. 1 of these 6 standards was met. Standards 2, 3 and 5 were not assessed at this visit and standard 6 was not applicable. The Statement of Purpose and Service User Guide were in place and were found to contain all the required information. These documents were available to prospective service users, their families and professionals involved in making a decision about whether the home would be suited to their individual needs. The staff employed at the home were found to have the skills and experience collectively to care for the service users accommodated. The registered provider will need to inform the service user that the home is able to meet his or her assessed needs on admission.Church Terrace Nursing & Residential HomePage 6 Health and Personal Care (Standards 7-11) 4 of these 5 were met. Each service user had an individual plan of care developed from an assessment of needs. Generally these plans had been updated and reviewed on a regular basis but there were inconsistencies with these. Service users or their representatives were consulted on their plans and had the opportunity to help maintain them. Individual healthcare needs were assessed and monitored on a regular basis. There was evidence of visits by GPs and other healthcare professionals. It was recommended in this report that the frequency of visits by the chiropodist be increased in order to ensure that all service users receive regular treatment. Policies and procedures were in place in relation to medication and had been adhered to by staff administering these. There was a policy in place for service users wishing to self medicate. The importance of the maintenance of Privacy and Dignity for service users within the Home was outlined in the Statement of Purpose and staff endeavoured to ensure that this was upheld. All bedrooms had the benefit of en-suite facilities. There was a policy on death and caring for the dying. Nursing and Care staff work closely with the GP to ensure that the service user receives adequate pain relief and are made as comfortable as possible at these times. Daily Life and Social Activities (Standards 12-15) 2 of these 4 standards were met. Standards 13 and 14 were not assessed at this visit. There was an activities programme within the home and care staff were observed relating to service users on an individual basis. A full time activities co-ordinator was employed by the home. This met the requirement from the previous inspection. There was evidence of service users making individual choices and these were catered for as much as possible. Likes and dislikes had been documented in relation to food, times of rising and retiring, preferred bathing/showering times and other areas of life in the home. The menus were seen to be varied and worked on a four weekly rota. The food served was seen to be wholesome and appetising. Special diets were catered for. Service users were complimentary about the food served. Complaints and Protection (Standards 16-18) 2 of the 3 standards were met. There was a clear and accessible complaints procedure in place and this was displayed in the home. This procedure will need to contain the details of the local NCSC area office at Stafford.Church Terrace Nursing & Residential HomePage 7 Whilst in the home service users were able to exercise their legal rights either directly or indirectly. Service users and their representatives could be assured that the policies and procedures in place at the home helped to protect them from harm. Environment (Standards 19-26) 7 of these 8 standards were met. The home was purpose built as a care home several years ago and was built on 2 floors. There was evidence that the redecoration and refurbishment programme had started to be implemented within the home and this must include the replacement of two easy chairs seen in Blossom Court unit as outlined in the previous requirements. It is a recommendation that the refurbishment programme also includes the provision of another accessible adapted bath on Autumn Leaves unit. There was adequate provision of indoor and outdoor communal facilities. There was a lounge/sitting room and dining area on each unit. Each bedroom had the benefit of en suite facilities and toilets were located in corridor areas close to communal rooms. Adaptations had been made to the home in order to maximise independence for service users. The number and sizes of bedrooms had been unchanged since the last announced. inspection. Comfortable accommodation was provided in all bedrooms and these had been personalised by the service users. The Home was centrally heated throughout and radiators were covered with a suitable guard. On the day of the inspection the Home felt warm and well ventilated. Rooms could be naturally ventilated and lighting was adequate. The Home was clean and hygienic on the day of the inspection. There was an adequate supply of domestic assistants and the laundry and kitchen were inspected. Staffing ­ Standards 27-30. 1 of these 4 standards was met. Standard 28 was not assessed at this visit. The numbers and skill mix of staff working at the home was found to be in keeping with the existing staffing notice and the dependencies of the service users. There was a thorough recruitment procedure in place and stringent checks were carried out on individuals before they were offered a permanent placement. Some of the staff members stated that they had not agreed terms and conditions of employment, and a requirement has been made in relation to this. There was a rolling programme of staff training and staff confirmed that their training needs Church Terrace Nursing & Residential Home Page 8 were met. New staff undergo a period of induction training overseen by a mentor. Management and Administration ­ Standards 31-38. 2 of these 8 standards were met. Standards 33, 34, 36 and 37 were not assessed at this visit. Standards 31 and 32 were almost met, as the new acting manager was very well qualified and experienced to manage the home but had not yet been registered by the NCSC. Service users, visitors and staff were all complimentary about the acting manager stating that she was both supportive and approachable. There was the provision of a secure facility in which service users could deposit their monies for safekeeping. Records and receipts were examined in relation to service users monies and were found to be in order. Documentation was examined in relation to the Health and Safety and maintenance of the environment. There was evidence of the testing and servicing of equipment. Mandatory staff training was on going and included fire drills. Policies and procedures within the home helped to ensure that a safe environment was maintained for service users, staff and visitors.Church Terrace Nursing & Residential HomePage 9 Requirements from last Inspection visit fully actioned? If No please list belowNOSTATUTORY REQUIREMENTS Identified below are areas not addressed from the last inspection report which indicate a non-compliance with the Care Standards Act 2000 and accompanying Regulations. No. Regulation Standard Required actions Timescale for action 8 23(2)(b, d) OP19 The easy chairs outlined in the Blossom Court unit will need repairing/replacing 5/9/03Action is being taken by the National Care Standards Commission to ensure compliance in regard to the above requirements. RECOMMENDATIONS Identified below are recommendations from the last inspection that have not been implemented No. Refer to Good Practice Recommendations StandardCONDITIONS OF REGISTRATION THAT APPLY (OTHER THAN NUMBERS AND CATEGORY OF SERVICE USERS).Met (Yes / No)Church Terrace Nursing & Residential HomePage 10 STATUTORY REQUIREMENTS IDENTIFIED DURING THE INSPECTION Action Plan: The Registered Person is requested to provide the Commission with an Action Plan, which indicates how requirements and recommendations are to be addressed with the time scale within which such actions will be taken. This action plan will be made available on request to the Area Office.STATUTORY REQUIREMENTS Identified below are areas addressed in the main body of the report, which indicate noncompliance with the Care Standards Act 2000, and accompanying Regulations 2001 and the National Minimum Standards. The Registered Provider(s) is/are required to comply within the given time scales. No. Regulation Standard * Requirement Timescale for action 1 14 OP4 It is a requirement that the registered provider confirms in writing to the service user that the Home is able to meet his or her assessed needs. It is a requirement that all care plans contain relevant risk assessments and are evaluated on a monthly basis. It is a requirement that the local NCSC name and address replaces the one displayed on the current complaints policy. By 20/4/04215OP7By 20/4/04322OP16By 20/4/04423(2)OP19There were two easy chairs, which were in need of repair/replacement on the Blossom Court unit. These had been highlighted at the By 20/5/04 previous inspection. It is a requirement that these chairs are now given priority on the refurbishment programme. The registered person must ensure that all staff have a written contract of employment, By 20/5/04 and must make it a condition of a position that the staff member signs this. The registered person must provide staffing levels that enable activities to be provided for service users. By 20/5/04.517(2) schedule 4OP29616(2)(m, n) OP12Church Terrace Nursing & Residential HomePage 11 RECOMMENDATIONS Identified below are areas addressed in the main body of the report, which relate to National Minimum Standards and are seen as good practice issues which should be considered for implementation by the registered Provider(s) No. Refer to Good Practice Recommendations Standard * 1 2 OP8 OP21 It is a recommendation that visits by the chiropodist be increased to ensure that all service users receive adequate foot care. It is a recommendation that the refurbishment programme includes the provision of another accessible adapted bath on this unit.* Note: You may refer to the relevant standard in the remainder of the report by omitting the 2-letter prefix e.g. OP10 refers to Standard 10.Church Terrace Nursing & Residential HomePage 12 PART BINSPECTION METHODS & FINDINGSThe following inspection methods have been used in the production of this report Direct Observation Indirect Observation Sampling · Pre-inspection Questionnaire · Records · Care Plans / Care Pathways · Meals · Activities · Other (Specify) `Tracking care and support Group discussion with service users Individual discussion with service users Group discussion with staff Individual discussion with staff Discussion with management Service user survey Relatives/significant others survey/feedback Visiting Professionals survey / feedback Tour of Premises Formal Interviews Document reading Additional Inspection Information: Number of Service Users spoken to at time of inspection Number of Relatives/significant others the inspectors had contact with Number of letters received in respect of the service CRB check for the Responsible Individual seen CRB check for the Manager seen Certificate of registration was displayed at the time of the inspection Certificate of registration accurately reflected the situation in the service at the time of inspection Total number of care staff employed (excluding managers) Total number of staff with nursing qualifications employed Date of Inspection Time of Inspection Duration Of Inspection (hrs) YES YES NO YES YES YES YES NO YES YES YES YES YES YES NO YES NO YES YES YES 22 3 0 NO NO YES YES 37 12 5/1/04 10AM 10.5Church Terrace Nursing & Residential HomePage 13 The following pages summarise the key findings and evidence from this inspection, together with the NCSC assessment of the extent to which the National Minimum Standards for Care homes for older persons have been met. The following scale is used to indicate the extent to which standards have been met or not met by placing the assessed level alongside the phrase Standard met? The scale ranges from: 4 - Standard Exceeded 3 - Standard Met 2 - Standard Almost Met 1 - Standard Not Met (Commendable) (No shortfalls) (Minor shortfalls) (Major shortfalls)0 or blank in the Standard met? box denotes standard not assessed on this occasion. 9 in the Standard met? box denotes standard not applicable. X is used where a percentage value or numerical value is not applicable.Church Terrace Nursing & Residential HomePage 14 Choice of HomeThe intended outcomes for the following set of standards are: · · · · · · 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.Standard 1 (1.1 ­ 1.3) The registered person produces and makes available to service users an up to date statement of purpose setting out the aims, objectives, philosophy of care, services and facilities and terms and conditions of the home; and provides a service users guide to the home for current and prospective residents. The statement of purpose clearly sets out the physical environmental standards met by a home in relation to standards 20.1, 20.4, 21.3, 21.4, 22.2, 22.5, 23.3 and 23.10: a summary of this information appears in the homes service users guide Range of fees charged From (£) 261.00 To (£) 436.00Any charges for extrasYESHAIRDRESSING CHIROPODY TOILETRIESIf yes, please state what the extras are: 3 Key findings/Evidence Standard met? The Statement of Purpose needed to be reviewed during this inspection, and it was found that of the 18 elements mentioned in Schedule one of the Regulations, 15 were fully met, 2 needed some expansion on the statements given, and 1 needed to have the words Older people replaced with the age band being catered for, i.e., over 65. These minor amendments were discussed with the management and do not constitute a reason for this standard not being met.Church Terrace Nursing & Residential HomePage 15 Standard 2 (2.1 ­ 2.2) Each service user is provided with a statement of terms and conditions at the point of moving into the home (or contract if purchasing their care privately). 0 Key findings/Evidence Standard met? The standard was not assessed at this visit.Standard 3 (3.1 ­ 3.5) New service users are admitted only on the basis of a full assessment undertaken by people trained to do so, and to which the prospective service user, his/her representatives (if any) and relevant professionals have been party. 0 Key findings/Evidence Standard met? The standard was not assessed at this visit.Standard 4 (4.1 - 4.4) The registered person is able to demonstrate the homes capacity to meet the assessed needs (including specialist needs) of individuals admitted to the home. 2 Key findings/Evidence Standard met? Staff were found to have the necessary skills and experience to care for the service users accommodated in the Home. Specialist services and equipment were accessed as required. The new manager in post brought a wealth of skills­both nursing and management to the Home. It is a requirement that the registered provider confirms in writing to the service user that the Home is able to meet his or her assessed needs. Standard 5 (5.1 ­ 5.3) The registered person ensures that prospective service users are invited to visit the home and to move in on a trial basis, before they and / or their representatives make a decision to stay; unplanned admissions are avoided where possible. 0 Key findings/Evidence Standard met? The standard was not assessed at this visitChurch Terrace Nursing & Residential HomePage 16 Standard 6 (6.1 - 6.5) Where service users are admitted only for intermediate care, dedicated accommodation is provided together with specialised facilities, equipment and staff to deliver short-term intensive rehabilitation and enable service users to return home. 9 Key findings/Evidence Standard met? The Home was not registered to offer this service.Church Terrace Nursing & Residential HomePage 17 Health and Personal CareThe intended outcomes for the following set of standards are: · · · · · The service users health, personal and social care needs are set out in an individual plan of care. Service users make decisions about their lives with assistance as needed. Service users, where appropriate, are responsible for their own medication, and are protected by the homes 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.Standard 7 (7.1 ­ 7.6) A service user plan of care generated from a comprehensive assessment (see Standard 3) is drawn up with each service user and provides the basis for the care to be delivered. 2 Key findings/Evidence Standard met? Each service user had a plan of care in place generated from an initial assessment of needs. There was some inconsistency with the standard of care planning throughout the different units. The plans on Autumn Leaves and Blossom Court were found to be comprehensive and regularly updated whilst the plans on Maple Dene and Oaklands were in need of further attention. It is a requirement that all care plans contain relevant risk assessments and are evaluated on a monthly basis. In one care plan on Maple Dene, there was an identified fire risk with the service user, but no corresponding documentation to show how this risk was being managed.Church Terrace Nursing & Residential HomePage 18 Standard 8 (8.1 ­ 8.13) The registered person promotes and maintains service users health and ensures access to health care services to meet assessed needs. Number of incidents where service users have been taken to Accident and Emergency during last 12 months Number of service users with pressure sores at time of inspection (from information taken from care notes)12 43 Key findings/Evidence Standard met? The provision of healthcare for service users was found to be good overall. GP visits and visits by other healthcare professionals had been monitored and recorded. It is a recommendation that visits by the chiropodist be increased to ensure that all service users receive adequate foot care. Psychological healthcare needs had been assessed and evaluated with specialist advice being sought from the Community Psychiatric Nurse and the Psychiatrist as required. Pressure sore risk had been assessed and pressure-relieving equipment was in use around the Home. There was evidence of care plans in place for the management of pressure sores and involvement by the specialist Tissue Viability Nurse Specialist. Nutrition had been assessed and monitored with service users being regularly weighed and advice sought from the dietician when indicated. Food supplements were obtained on prescription. Medical conditions had been assessed and monitored such as diabetes and epilepsy with care plans in place for individual service users. There was evidence of the treatment of infections such as urinary tract and upper respiratory tract infections, with care plans in place for these and visits by the GP accessed and documented. Visits to the Home by the Optician and Dentist had taken place.Church Terrace Nursing & Residential HomePage 19 Standard 9 (9.1 ­ 9.11) The registered person ensures that there is a policy and staff adhere to the procedures for the receipt, recording, storage, handling administration and disposal of medicines, and service users are able to take responsibility for their own medication if they wish, within a risk management framework. 3 Key findings/Evidence Standard Met? There were policies and procedures in place for the receipt, storage, administration and disposal/return of medication. Staff were adhering to these policies and Medication Administration Record sheets had been completed as required. There was a Homely Remedies Policy in place signed by the GP. All medication was found to have been labelled correctly and was in date. The staff stated that they received good support from the pharmacist who would give advice and training as needed. There was a policy in place for service users wishing to self-medicate. Standard 10 (10.1 ­ 10.7) The arrangements for health and personal care ensure that service users privacy and dignity are respected at all times, and with particular regard to: personal care giving, including nursing, bathing, washing, using the toilet or commode, consultation with and examination by health and social care professionals, consultation with legal and financial advisors, maintaining social contacts with relatives and friends, entering bedrooms, toilets and bathrooms, and following death. 3 Key findings/Evidence Standard met? The importance of the maintenance of Privacy and Dignity for service users within the Home was outlined in the Statement of Purpose and staff endeavoured to ensure that this was upheld. Staff were observed knocking on bedroom doors before entering and service users were taken to the toilet discreetly. All rooms had the benefit of en suite facilities and personal care was carried out in bedrooms. Shared rooms had privacy screens in place. Service users were able to make telephone calls either from their own room or using the plug in mobile phone. However, on Autumn Leaves the inspector noticed that the bath list was pinned up in the lounge, and asked for it to be removed from such a public place, where other service users visitors were able to read it.Church Terrace Nursing & Residential HomePage 20 Standard 11 (11.1 ­ 11.12). Care and comfort are given to service users who are dying, their death is handled with dignity and propriety, and their spiritual needs, rites and functions observed. 3 Key findings/Evidence Standard met? There was a policy in place in relation to Care of the Dying and Care Following Death. Emphasis was on the maintenance of privacy and dignity and service users and their representatives were treated with sensitivity and respect. Spiritual needs were upheld with visits from the local clergy encouraged and accessed if this is desired by the service user. Nursing and Care staff work closely with the GP to ensure that the service user receives adequate pain relief and is made as comfortable as possible.Church Terrace Nursing & Residential HomePage 21 Daily Life and Social ActivitiesThe intended outcomes for the following set of standards are: · · · · 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.Standard 12 (12.1 ­ 12.4) The routines of daily living and activities made available are flexible and varied to suit service users expectations, preferences and capacities. 2 Key findings/Evidence Standard met? The inspector learned that there are 40 hours of a carers time dedicated to organising and enabling activities in the home. On the Dementia Care unit it was encouraging to see a lady receiving a manicure and hand massage. The smile on her face and her general demeanour suggested that she appreciated this one to one attention. Her carer stated that on that particular unit she had found it more fruitful to work individually, and for short periods as befits the attention span of the resident service users. It was a previous requirement that the home employs an activities co-ordinator and the provision of activities for service users needs to be arranged. Standard 13 (13.1 ­ 13.6) Service users are able to have visitors at any reasonable time and links with the local community are developed and/or maintained in accordance with service users preferences 0 Key findings/Evidence Standard met? The standard was not assessed at this visit.Church Terrace Nursing & Residential HomePage 22 Standard 14 (14.1 ­ 14.5) The registered person conducts the home so as to maximise service users capacity to exercise personal autonomy and choice. 3 Key findings/Evidence Standard met? Service users were able to handle their own finances for as long as they wished or were able to. The use of advocacy services was discussed with the Manager and she was aware of how to access this facility should the need arise. Service users were able to bring personal possessions into the Home following agreement by the Manager and there was evidence of this throughout the bedrooms. Standard 15 (15.1 ­ 15.9) The registered person ensures that service users receive a varied, appealing, wholesome and nutritious diet which is suited to individual, assessed and recorded requirements and that meals are taken in a congenial setting and at flexible times. 3 Key findings/Evidence Standard met? Each service user had an individual four-week menu, which catered for their choices. Three meals were offered each day along with snacks and hot and cold drinks throughout the day. The staff were seen to offer discreet support to some service users who needed assistance at meal times. Special diets and requirements were catered for as necessary. Meal times were seen to be unhurried and relaxed. Service users spoke highly of the food served.Church Terrace Nursing & Residential HomePage 23 Complaints and ProtectionThe intended outcomes for the following set of standards are: · · · 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.Standard 16 (16.1 ­ 16.4) The registered person ensures that there is a simple clear and accessible complaints procedure which includes the stages and time-scales for the process and that complaints are dealt with promptly and effectively. No. of complaints made to the home during last 12 months No. of these complaints fully substantiated No. of these complaints partly substantiated No. of these complaints not substantiated No. of these complaints not yet resolved No. of complaints sent direct to NCSC Percentage of complaints responded to within 28 days 3 1 1 0 1 1 100 2Key findings/Evidence Standard met? There was a clear and accessible complaints policy in place in the Home.The policy displayed on the wall in the office contained the details of the previous inspection Authority. It is a requirement that the local NCSC name and address replaces the one displayed on the current complaints policy. Standard 17 (17.1 ­ 17.3) Service users have their legal rights protected, are enabled to exercise their legal rights directly and participate in the civic process if they wish. 3 Key findings/Evidence Standard met? Service users had their legal rights protected whilst accommodated in the Home. Some service users used the services of solicitors. Service users were able to participate in the political process and could vote at election times by either postal votes or attend the local polling station if able to do so.Church Terrace Nursing & Residential HomePage 24 Standard 18 (18.1 ­ 18.6) The registered person ensures that service users are safeguarded from physical, financial, or material, psychological or sexual abuse, neglect, discriminatory abuse or self harm, inhuman or degrading treatment through deliberate intent, negligence or ignorance, in accordance with written policies. The home has an Adult Protection procedure (including Whistle Blowing) which complies with the Public Disclosure Act 1998 and the Department of Health Guidance No Secrets No. of staff referred for inclusion on POVA lists YES X3 Key findings/Evidence Standard met? The home has a copy of the adult protection policies and notices telling resident service users how they could contact an advocate, The inspector also undertook a formal interview with a member of the care staff, who demonstrated that she had a good understanding of the issues surrounding abuse, who could commit it, what forms it might take, and what procedures she should follow if she suspected it in the home.Church Terrace Nursing & Residential HomePage 25 EnvironmentThe intended outcomes for the following set of standards are: · · · · · · · · 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.Standard 19 (19.1 ­ 19.6) The location and layout of the home is suitable for its stated purpose; it is accessible, safe and well maintained; meets service users individual and collective needs in a comfortable and homely way and has been designed with reference to relevant guidance. 2 Key findings/Evidence Standard met? There was evidence that the redecoration programme had started to be implemented and this was on going. The broken blinds in Blossom Court conservatory had been removed. There were two chairs in this area, which were in need of replacing/repairing. These had been highlighted at the previous inspection. It is a requirement that these chairs are now given priority on the refurbishment programme. Standard 20. (20.1 ­ 20.7) In all newly built homes and first time registrations the home provides sitting, recreational and dining space (referred to collectively as communal space) apart from service users private accommodation and excluding corridors and entrance hall amounting to at least 4.1 sq. metres for each service user. 3 Key findings/Evidence Standard met? There was adequate provision of indoor and outdoor communal facilities. There was a lounge/sitting room and dining area on each unit. Lighting and furniture was adequate and domestic in character.Church Terrace Nursing & Residential HomePage 26 Standard 21 (21.1 ­ 21.8) Toilet, washing and bathing facilities are provided to meet the needs of service users. 3 Key findings/Evidence Standard met? Each bedroom had the benefit of en suite facilities. Toilets were located in corridor areas close to communal rooms. Some of the baths were noted as being unusable on Autumn Leaves as one did not have any arms on the bath hoist and the other did not have a bath hoist fixed. It is a recommendation that the refurbishment programme includes the provision of another accessible adapted bath on this unit. However, in one toilet, the inspector pointed out that the paper towel holder was broken, and needed replacing. Standard 22 (22.1 ­ 22.8) The registered person demonstrates that an assessment of the premises and facilities has been made by suitably qualified persons including a qualified occupational therapist, with specialist knowledge of the client groups catered for and provides evidence that the recommended disability equipment has been secured or provided and environmental adaptations made to meet the needs of service users. 3 Key findings/Evidence Standard met? The quality of life for service users was maximised and improved by the use of specialist equipment. Mattresses, hoists, bath aids, bath chairs and grab rails were all available in the different units. The provision of another adapted bath on the Autumn Leaves unit is recommended. Storage was limited, however service users preferred to keep their wheelchairs in their rooms for convenience. The nurse call system was available in all areas and was seen and heard to be working on the day of inspection.Church Terrace Nursing & Residential HomePage 27 Standard 23 (23.1 ­ 23.11) The home provides accommodation for each service user which meets minimum space as prescribed Total number of single bedrooms with at least 10 sq.m usable space or additional compensatory space Pre-existing homes only (1 April 2003) - single bedrooms below 10 sq.m usable space or additional compensatory space Total number of wheelchair users accommodated for in rooms at least 12sq.m Total number of wheelchair users accommodated for in rooms at less than 12sq.m Total number of shared rooms at least 16 sq.m Total number shared rooms less than 16 sq.m Percentage of places within single rooms: 100 80 - 99 Less than 80 Total number of single bedrooms Total number of single rooms with en suite Total number of double rooms Total number of double rooms with en suite NO NO YES 43 43 14 14 43 020 0 14 03 Key findings/Evidence Standard met? The number and sizes of bedrooms had been unchanged since the last announced inspection.Church Terrace Nursing & Residential HomePage 28 Standard 24 (24.1 ­ 24.8) The home provides private accommodation for each service user, which is furnished and equipped to assure comfort and privacy and meets the assessed needs of the service user. 3 Key findings/Evidence Standard met? Comfortable accommodation was provided in all bedrooms and these had been personalised by the service users. In the bedroom where a service users clock was showing the wrong time, a member of staff was dispatched to fetch a new battery. Standard 25 (25.1 ­ 25 8) The heating, lighting, water supply and ventilation of service users accommodation meet the relevant environmental health and safety requirements and the needs of individual service users. 3 Key findings/Evidence Standard met? The Home was centrally heated throughout and radiators were covered with a suitable guard. On the day of the inspection the Home felt warm and well ventilated. Rooms could be naturally ventilated and lighting was adequate. Emergency lighting was provided throughout. Standard 26 (26.1 ­ 26.9) The premises are kept clean, hygienic and free from offensive odours throughout and systems are in place to control the spread of infection in accordance with relevant legislation and published professional guidance. 3 Key findings/Evidence Standard met? The Home was clean and hygienic on the day of the inspection. There was an adequate supply of domestic assistants and the laundry and kitchen were inspected. Cleaning schedules were in place and COSHH regulations were observed.Church Terrace Nursing & Residential HomePage 29 StaffingThe intended outcomes for the following set of standards are: · · · · 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 homes recruitment policy and practices. Staff are trained and competent to do their jobs.Standard 27 (27.1 ­ 27.7) Staffing numbers and skill mix of qualified/unqualified staff are appropriate to the assessed need of the service users, the size, the layout and purpose of the home, at all times. Number of staff /hours in respect of service user needs based on guidance recommended by Department of Health. Personal Nursing Care No. service users High No. staff hours 33 X X needs allocated No. service users Medium needs No. service users Low needs No. of staff hours required No. of full time equivalent first level registered nurses No. of care staff No. of ancillary staff Key findings/Evidence 30 0 1200 No. staff hours allocated No. staff hours allocated No. of staff hours provided X X 2080 X X X9.5 37 12 Standard met? 3Church Terrace Nursing & Residential HomePage 30 The above staffing hours provided were for a total of both care and nursing staff per week in the Home. There was a total of 66 service users accommodated in the home at the time of the inspection. The staffing numbers and skill mix of the staff on day duty was found to be appropriate. The units were staffed accordingly. Each of the nursing units had a trained nurse on duty from 8am-8pm with three care staff. There were 18 service users accommodated on Oak lands and Autumn Leaves units and 19 on Maple Dene. On night duty there was two nurses on duty (covering 3 nursing units), with 5 care staff covering all units. On the residential unit (Blossom Court) there was 2 care staff on duty (one was a senior care assistant) 8am-8pm and 1 care assistant on night duty for 11 service users. There were 5 domestic staff on duty daily from 8am-12.30pm including weekends. There was a kitchen assistant on duty from 7am-7pm and a cook from 7.30am-6.30pm daily. The laundry assistants worked from either 8am-5pm or 9am-6pm daily. There was a full time maintenance person employed and a full time administrator. The administrators position was vacant at the time of the inspection. The Manager worked full time and was completely supa numery. Standard 28 (28.1 ­ 28.3) A minimum ratio of 50 trained members of care staff (NVQ Level 2 or equivalent) is achieved by 2005, excluding the registered manager and/or care manager, and in care homes providing nursing, excluding those members of care staff who are registered nurses. No. care staff (excluding registered nurses) with NVQ level 2 or equivalent of care staff with NVQ level 2 Key findings/Evidence The standard was not assessed at this visit X X Standard met? 0Standard 29 (29.1 ­ 29.6) The registered person operates a thorough recruitment procedure based on equal opportunities and ensuring the protection of service users. 2 Key findings/Evidence Standard met? The inspector talked with several members of staff, and understands that not all had agreed contracts of employment. A subsequent requirement has been made. CRB police checks had been carried out as required.Church Terrace Nursing & Residential HomePage 31 Standard 30 (30.1 ­ 30.4) The registered person ensures that there is a staff training and development programme, which meets the National Training Organisation (NTO) workforce training targets and ensures staff fulfil the aims of the home and meet the changing needs of service users. 3 Key findings/Evidence Standard met? Staff recounted several items of training, which they had received collectively and as individuals, and the rolling program of in house training continued on the day of the inspection with a session on best practice in food hygiene.Church Terrace Nursing & Residential HomePage 32 Management and AdministrationThe intended outcomes for the following set of standards are: · · · · · · · · 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 homes record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected.Standard 31 (31.1 ­ 31.8) The registered manager is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives. 2 Key findings/Evidence Standard met? The proprietor had recently appointed the acting manager. She was a first level trained nurse with many years experience in general nursing and care of the elderly. She had previous experience of managing a large Nursing Home. The acting manager had obtained an MBA and Diploma in Management Studies. The acting manager had put forward her application to become the Registered Manager of the Home at the time of the inspection. The above scoring of 2 reflects the fact that there was no Registered Manager at the Home at the time of the inspection. Standard 32 (32.1 ­ 32.7) The registered manager ensures that the management approach of the home creates an open, positive and inclusive atmosphere. 2 Key findings/Evidence Standard met? This standard was difficult to assess as the acting manager had only been in post for a short time. On speaking to staff they were complimentary about the support they had recently received from her. Meetings had taken place and had been arranged for all staff. Some of the service users spoken to stated that they had met the acting manager and had found her approachable.Church Terrace Nursing & Residential HomePage 33 Standard 33 (33.1 ­ 33.10) Effective quality assurance and quality monitoring systems, based on seeking the views of service users are in place to measure success in meeting the aims, objectives and the statement of purpose of the home. 0 Key findings/Evidence Standard met? The standard was not assessed at this visitStandard 34 (34.1 ­ 34.5) Suitable accounting and financial procedures are adopted to demonstrate current financial viability and to ensure that there is effective and efficient management of the business. 0 Key findings/Evidence Standard met? The standard was not assessed at this visitStandard 35 (35.1 ­ 35.6) The registered manager ensures that service users control their own money except where they state that they do not wish to or they lack capacity and that safeguards are in place to protect the interests of the service user. Number of service users subject to Power of Attorney processes Number of service users subject to Enduring Power of Attorney processes Number of service users subject to Guardianship Orders X X X3 Key findings/Evidence Standard met? The recently appointed manager was not aware of the above information and was in the process of obtaining this from relatives. A random sample of service users monies was checked and found to tally with the documentation, which was itself of the appropriate standard. The homes proprietor did act as agent for the benefits of some of the resident service users.Church Terrace Nursing & Residential HomePage 34 Standard 36 (36.1 ­ 36.5) The registered person ensures that the employment policies and procedures adopted by the home and its induction, training and supervision arrangements are put into practice. 0 Key findings/Evidence Standard met? The standard was not assessed at this visitStandard 37 (37.1 ­ 37.3) Records required by regulation for the protection of service users and for the effective and efficient running of the business are maintained, up to date and accurate. 0 Key findings/Evidence Standard met? The standard was not assessed at this visitStandard 38 (38.1 ­ 38.9) The registered manager ensures so far as is reasonably practicable, the health, safety and welfare of service users and staff. 3 Key findings/Evidence Standard met? Documentation was examined in relation to the Health and Safety and maintenance of the environment. Policies and procedures had been reviewed in January 2003 and were due for renewal. Records had been maintained in relation to the testing of fire detecting and fire fighting equipment. Water temperatures had been tested regularly. Portable Electrical Equipment had been tested. Equipment used for the efficient running of the Home had been serviced using contractors. This included fixed and portable hoists, the passenger lift, gas and electrical equipment and the central heating boiler. Staff mandatory training including moving and handling, fire safety and COSHH had been carried out and updated. Staff had received fire drills but it is recommended that these be carried out more frequently to ensure that all staff receive regular drills.Church Terrace Nursing & Residential HomePage 35 PART C(where applicable)COMPLIANCE WITH CONDITIONSCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceCondition CommentsComplianceChurch Terrace Nursing & Residential HomePage 36 PART DD.1PROVIDERS RESPONSE TO IDENTIFIED STATUTORY REQUIREMENTSRegistered Persons comments/confirmation relating to the content and accuracy of the report for the above inspection.We would welcome comments on the content of this report relating to the Inspection conducted on 5 January 2004 and any factual inaccuracies: Please limit your comments to one side of A4 if possible Providers comments and an action plan are available at the Stafford Office, where these have been submitted.Church Terrace Nursing & Residential HomePage 37 Action taken by the NCSC in response to provider comments: Amendments to the report were necessary YESComments were received from the provider Provider comments/factual amendments were incorporated into the final inspection report Provider comments are available on file at the Area Office but have not been incorporated into the final inspection report. The inspector believes the report to be factually accurateYESYESNONote: In instances where there is a major difference of view between the Inspector and the Registered Provider both views will be made available on request to the Area Office. D.2 Please provide the Commission with a written Action Plan by 26 April 2004 , which indicates how requirements are to be addressed and stating a clear timescale for completion. This will be kept on file and made available on request. You will also note that the Commission has identified in the inspection report good practice recommendations and it would be useful to have some indication as to whether you intend to take any action to progress these. Status of the Providers Action Plan at time of publication of the final inspection report: Action plan was required YESAction plan was received at the point of publicationYESAction plan covers all the statutory requirements in a timely fashion Action plan did not cover all the statutory requirements and required further discussion Provider has declined to provide an action plan NOOther:NOChurch Terrace Nursing & Residential HomePage 38 D.3PROVIDERS AGREEMENT Registered Persons statement of agreement/comments: Please complete the relevant section that applies.D.3.1 I of confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) and that I agree with the requirements made and will seek to comply with these. Print Name Signature Designation Date Or D.3.2 I of am unable to confirm that the contents of this report are a fair and accurate representation of the facts relating to the inspection conducted on the above date(s) for the following reasons:Print Name Signature Designation Date Note: In instance where there is a profound difference of view between the Inspector and the Registered Provider both views will be reported. Please attach any extra pages, as applicable.Church Terrace Nursing & Residential HomePage 39 - 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. 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