Inspection on 01/10/07 for Church View

This inspection was carried out on 1st October 2007.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. The way we rate inspection reports is consistent for all houses, though please be aware that this may be different from an official CSCI judgement.

The inspector found no outstanding requirements from the previous inspection report, but made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church View 22/05/06

Church View 07/09/05

Church View 25/04/05

Church View 13/09/04

Church View 11/05/04

Similar services:

22 Sandown Road

The Highlands

Dilston College Of Further Education

West View House

Prince Bishop Court

Park View (15)

Craigmore House

1 Lanark Close

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

CARE HOME ADULTS 18-65 Church View Kirkleatham Village Redcar TS10 5NW Lead Inspector Ray Burton Unannounced Inspection 1 October 2007 10:00 st Church View DS0000000105.V351824.R01.S.doc Version 5.2 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 View DS0000000105.V351824.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 Adults 18-65. 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 View DS0000000105.V351824.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church View Address Kirkleatham Village Redcar TS10 5NW 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) 01642 283320/21 Tees and North East Yorkshire NHS Trust Mrs Marsha Gregson Care Home 8 Category(ies) of Learning disability (8) registration, with number of places Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 22nd May 2006 Brief Description of the Service: Church View is owned and operated by Tees and North East Yorkshire NHS Trust and is registered under the Care Standards Act 2000 to accommodate 8 people under the age of sixty-five with learning disabilities (LD). It is a large detached property in a rural location in its own large garden. The home is divided into two units, upstairs and downstairs each with four single bedrooms, though this division is not rigidly applied. The bedrooms all meet the size requirements of the Care Homes for Adults (18-65) National Minimum Standards and have a hand basin fitted. None is equipped with ensuite bathroom or toilet facilities. Both upstairs and downstairs areas have their own kitchen, bathroom and communal areas. The care needs of the people who live at Church View needs are high and support is provided by the staff team with the support of external professionals and agencies. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection covering all of the key standards of the National Minimum Standards for Care Homes for Adults. The inspection commenced on 1st October and was completed on 10th December 2007. During the inspection a tour of the building was conducted, records and care plans examined and the inspector spoke to relatives, the newly appointed manager and members of staff. What the service does well: 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 View DS0000000105.V351824.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): #2,3, 4. People who use the service experience good quality outcomes in this area. The homes assessment procedure ensured that only those whose needs could be met would be admitted. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: There had been no recent admissions to the home however care plans evidenced that prior to admission a thorough multi-disciplinary assessment had been conducted to ensure the home would be able to meet needs. The manager confirmed that future admissions would also be preceded by robust assessments conducted over a period of time during which any prospective resident would be gradually introduced to the home and would be given the opportunity to meet existing residents and the staff team. Admissions would be followed by a trial period before a final decision was made about the suitability of the placement. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 8 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 6, 7, 8, 9. People who use the service experience good quality outcomes in this area. The homes care planning process ensured resident needs were identified and met. Residents were placed at the centre of the care planning process and were supported to make choices and take control of their lives at a level appropriate to their skills and abilities. Risk assessments and risk management strategies were comprehensive and detailed. We have made this judgement using a range of evidence, including a visit to the service. EVIDENCE: Examination of four randomly selected service user files evidenced that residents received good personal and individual support. Each file showed how the resident was put at the centre of the care planning process and had been involved at an appropriate level in the making of decisions. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 9 Each file contained a “Brief Assessment” that gave a very clear and concise picture of the resident and his/her history from birth. Significant people and events were listed. Special conditions, healthcare needs, behavioural difficulties, likes/dislikes and leisure activities etc were recorded. Thorough initial assessments were carried out covering all aspects of the resident’s life: mobility, personal care, feeding, communication etc. Continuous monitoring and re-assessment ensured changing needs were identified and met. Care plans, which had each been developed with the co-operation of relatives and appropriate professionals, showed how needs would be met; and it was evident that staff encouraged and supported residents to be involved at an appropriate level in the development of their own plan and to make decisions about everyday things affecting their lives. Where possible residents were encouraged to be involved with the day-to-day running of the home and to participate in simple household tasks e.g: helping in the kitchen by sharing in baking activities such as putting ingredients into a bowl, mixing with a spoon, fetching utensils, wiping down working surface etc. Comprehensive and detailed risk assessments were conducted and risk management strategies put in place with cognisance given to the effect different environment and situations could have on behaviour. An example of good risk assessment and risk management was the very detailed protocol in place for outings in the car, which included precise directions to staff about resident mix and compatibility, seating configuration, staffing ratios etc. Care plans showed how personalised fire evacuation procedures had been developed to meet the needs of individual residents. Residents were consulted about issues affecting their lives and were helped to express their needs and wishes. For those residents without speech, alternative means of communication were used: signing, pointing, gesture etc. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12, 13, 14, 15, 16, 17. People who use the service experience good quality outcomes in this area. Residents were presented with opportunities to lead fulfilling lives. Staff encouraged residents to take part in appropriate leisure activities and supported them when engaging in community activities. Staff encouraged the maintenance of family and friendship links. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans showed residents were encouraged and supported to develop their skills, to lead satisfying lives and to achieve as much independence as possible. Careful recording of achievements and any significant positive events, no matter how small, showed a strong commitment to helping residents to build on their strengths and maximise their potential. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 11 Activity plans showed each resident was provided with opportunity to take part in a range of suitable leisure activities both in-house and community based: listening to music, walks in the garden, swimming, picnics, trips to the countryside and beach, pub meals, McDonalds etc. Two residents attended day care services. Holidays were tailored to suit each resident and to meet his/her individual needs. Staff recognised the importance of residents’ maintaining contact with their family and friends and helped them to keep in touch by sending cards for special occasions such as Christmas and birthdays. One resident’s family lived abroad and staff had sent emails and video recordings to them so that they could see their relative and be reassured he was well Special occasions were celebrated with parties to which relatives, friends and former members of staff were invited. Conversation with staff and examination of records of food served showed residents were given a wide choice of food that reflected dietary requirements and individual preferences. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19, 20. People who use the service experience good quality outcomes in this area. Healthcare and personal needs were met by staff who provided support in a sensitive and flexible manner in accordance with the wishes of the individual resident. This judgement has been made using available evidence including a visit to this service. EVIDENCE: Care plans contained information about the resident’s general health, dietary requirements and details of any specific ailment or medical condition. Some of the residents had complex needs and the plans showed how the home worked as part of a multi-disciplinary team to ensure each resident received the specialist input that was required to enable their needs to be met. Conversation with members of staff and examination of care plans revealed an awareness of providing personal support in a sensitive and flexible manner; and of consulting with residents and supporting them to maintain as much independence and control over their own lives as possible. Since the last inspection the home had developed a user-friendly booklet “My Health Check” Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 13 that emphasised the importance of placing each resident at the centre of his/her own care; and helped promote independence in a format using pictures that would be understandable to the individual and would meet his/her needs. None of the residents had been assessed as being able to control their own medication. All medicines were stored appropriately and administered according to the homes policy and procedures by staff who had undergone suitable training. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 14 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 22, 23. People who use the service experience good quality outcomes in this area. The home had a suitable complaints procedure and policies and procedures to safeguard residents from abuse. Staff had received training in adult protection. We have made this judgement using a range of evidence including a visit to this service. EVIDENCE: The home had an appropriate complaints procedure stating how complaints could be made, who would deal with them, the timescale for the process and what to do if not satisfied with the way in which the matter had been handled. A user-friendly complaints procedure was being devised. Records showed that no complaints had been received since the last inspection. Three relatives told the inspector they did not have any complaints about the running of the home or about any aspect of the care given. One said he was satisfied with the service and that any minor concerns he had had in the past had always been dealt with appropriately. Policies and procedures were in place to ensure the safety and protection of residents and to respond to any suspicion or allegation of abuse, however these should be updated to reflect the change in management of the home. Staff had all received Protection of Vulnerable Adults (POVA) training and were able to demonstrate an understanding of what constituted abuse and what to do in the event of such an incident being brought to their attention. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 15 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 25, 27, 28, 30 People who use the service experience good quality outcomes in this area. The home provides comfortable and safe accommodation and meets the needs of the people living there. There were a few environmental issues that required addressing. We have made this judgement statement using a range of evidence, including a visit to this service. EVIDENCE: Church View has been divided into two self-contained units each providing accommodation for four people. Each unit has a lounge, dining room and kitchen. Outside is a large and pleasant garden that provides a good outdoor facility for residents to enjoy. Communal areas were well appointed with furniture that was domestic in nature and suitable for purpose. Bedrooms were nicely decorated and comfortably and suitably furnished, each had been individualised to reflect the personality of the occupant. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 16 Although, since the last inspection, there had been a general improvement in the environmental standard of the home there were some areas requiring upgrading: Bathrooms were rather austere and would benefit from a facelift to make them more welcoming; the stair carpet was badly stained and should be replaced; the entrance hall was unwelcoming and would benefit from being redecorated. Some of the windows in communal areas did not have curtains; it is appreciated that the behavioural problems associated with some of the residents has resulted in the frequent pulling down of curtains, however alternative means of dressing windows must be explored to ensure the privacy of residents and to improve the appearance of the home. It was of concern that a freezer containing food was situated in the ground floor laundry room. The freezer must be removed from the laundry room and relocated to a more appropriate site, away from the risk of contamination from soiled linen. The home was maintained in a clean and hygienic condition and was free from unpleasant odours. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35. People who use the service experience good quality outcomes in this area. Residents were protected by a competent staff team and by the homes policies and procedures on recruitment and training. We have made this judgement using a range of evidence, including as visit to this service. EVIDENCE: On the days of the inspection there were sufficient numbers of staff on duty to meet the needs of residents. Examination of staffing rosters indicated the home was always well staffed. The home followed the Tees and North East Yorkshire NHS Trust recruitment policies and procedures that ensured a rigorous selection process was adhered to. Examination of six personnel files revealed all required information was in place and that prior to confirmation of employment two suitable references were obtained and all necessary checks, including Criminal Record Bureau (CRB), had been conducted. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 18 The staff team comprised qualified nurses and care staff supported by domestic staff. Training records and conversation with staff revealed the home had a good training policy and all members of staff were encouraged to undertake training that would aid their professional development and help them meet resident needs. The mother of one of the residents said: “Because he had lived for so long at his old placement we were concerned he might not settle at Church View, however he has settled very well and seems to be very happy. I feel the staff look after him very well, as they do for all the residents.” There was a supervision policy in place ensuring each member of staff received at least six formal supervision sessions a year. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 19 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, 40, 41, 42. People who use the service experience good quality outcomes in this area. A well managed home with a competent staff team. The health, safety and welfare of residents are protected by the homes record keeping and policies and procedures. We have made this judgement using a range of evidence, including a visit to this service. EVIDENCE: A new manager has been appointed to the home and took up her position on 1st October; she has a suitable management qualification and is a Registered Nurse (Learning Disabilities). She is currently awaiting registration by the Commission for Social Care Inspection. The home had policies and procedures that complied with current legislation and recognised professional standards and covered all aspects of the management of the home. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 20 Records were kept to safeguard residents’ rights and best interests and to ensure the safe and effective running of the home; these were up-to-date and stored appropriately. Members of staff were aware of their responsibilities under health & safety legislation. Policies and procedures were in place to cover the health, safety and welfare of residents and staff. Regular checks of the building and equipment were carried out and maintenance and servicing undertaken to ensure a safe and comfortable environment. The home had various systems, both formal and informal, to measure success in meeting its aims and objectives and statement of purpose and to ensure residents rights and best interests were safeguarded: Trust-wide learning disability audit, annual questionnaire, residents reviews, staff supervision and appraisals, personal development plans for all staff. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 21 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 X 2 3 3 3 4 3 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 3 26 X 27 3 28 3 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 3 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 X LIFESTYLES Standard No Score 11 3 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 X 3 X 3 3 3 3 X Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 22 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 2 Standard YA24 YA24 Regulation 23 16(2)(g) Requirement The stained stair carpet must be replaced. The freezer containing food must be removed from the laundry. Timescale for action 01/03/08 15/01/08 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 2 3 Refer to Standard YA24 YA24 YA24 Good Practice Recommendations Bathrooms should be upgraded to make them more welcoming. Suitable means of securing curtains/window dressings should be explored to enhance the appearance of communal areas and to ensure privacy. The entrance hall required redecorating to make it more welcoming. Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 23 Commission for Social Care Inspection St Nicholas Building St Nicholas Street Newcastle upon Tyne NE1 1NB 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. Extracts may not be used or reproduced without the express permission of CSCI Church View DS0000000105.V351824.R01.S.doc Version 5.2 Page 24 - 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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