Inspection on 15/01/08 for Church View

This inspection was carried out on 15th January 2008.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church View 19/01/09

Church View 02/07/07

Church View 05/07/06

Church View 12/12/05

Church View 21/06/05

Church View 30/11/04

Church View 01/06/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Church View Church Street Kimberworth Rotherham South Yorkshire S61 1EW Lead Inspector Sarah Powell Key Unannounced Inspection 15 & 29th January 2008 09:00 th DS0000003120.V355672.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 DS0000003120.V355672.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. DS0000003120.V355672.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church View Address Church Street Kimberworth Rotherham South Yorkshire S61 1EW 01709 557 658 01709 550 541 church.view@craegmoor.co.uk www.craegmoor.co.uk Parkcare Homes Ltd 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) Mrs Emma Taylor Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places DS0000003120.V355672.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one named resident over the age of 65. Date of last inspection 2nd July 2007 Brief Description of the Service: Church View is a care home registered to provide care for 23 people with a diagnosis of mental illness. The home provides 24-hour care for people with enduring mental health needs. It encourages self-sufficiency and self-reliance where possible via a combination of staff support, and the teaching of independent living skills. The aim is to combine this with appropriate day care education and work experience, to encourage and foster social and community skills. Church View is organised into 3 separate houses, Vicarage, Canterbury, and York, all self contained, with single bedroom accommodation, bathroom/ toilet facilities, and separate kitchen, dining room and lounge facilities in the units. The fees at Church View at the time of the inspection ranged from £314 to £903 per week, however this is different for each person at the home as it is calculated on the needs of each person. It is therefore necessary to contact the home for further information. The registered person makes information about the service available via the Statement of Purpose, and the Service User Guide. DS0000003120.V355672.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 1 star. This means that the people who use this service experience adequate quality outcomes. This was an unannounced visit which took place over two days, commencing on 15 January at 9.30am until 14.00 and the second day on 29 January 2008 at 9.30 until 13.30 hrs. A total of 8.5 hours was spent in the home. A random visit was carried out on 2 October 2007; this was to meet the new manager and check on the progress of the requirements. The visit included talking with people living at the home, the manager, six staff and professionals. We also walked round the building to gain an overview of the facilities and we checked some records. Some surveys forms were sent to people who live at the home and their relatives. At the time of this visit, five were completed and returned to the Commission. The comments received were mostly positive. The manager completed an annual quality assurance assessment (AQAA) and returned this prior to the visit. This focuses on how well outcomes are being met for the people using the service. It also gives us some numerical information about the service. What the service does well: What has improved since the last inspection? We saw a large number of improvements during this visit. The environment was being re-furbished and redecorated. The grounds were also being landscaped. This will provide a large patio area with a water feature and seating for the people to be able to enjoy the outside space in the summer. Care plans now identified the people’s needs and were able to meet them. New care plans were also in the process of being implemented to ensure all needs are identified and met. DS0000003120.V355672.R01.S.doc Version 5.2 Page 6 Activities are much improved with 30 hours dedicated hours provided. Care staff also provided in house activities. People told us, “Activities are good now we have quizzes and baking”. Healthy and nutritious meals were now provided ensuring the people receive a good diet with choices available. The new manager is in post and registered with Commission for Social Care Inspection. She continues to make improvements in the home to provide a good quality service for the people who live there. 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. DS0000003120.V355672.R01.S.doc Version 5.2 Page 7 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 DS0000003120.V355672.R01.S.doc Version 5.2 Page 8 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 People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People in the home had their needs assessed prior to moving into the home to ensure they could be met. EVIDENCE: Suitably qualified staff carried out the pre admission assessments on people who wanted to move into the home. The assessments were very detailed with all people’s needs identified, ensuring that the home could meet their needs before a place was offered to them. DS0000003120.V355672.R01.S.doc Version 5.2 Page 9 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 & 9. People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Each person in the home had a plan of care with identified needs, however not all mental health needs were met. People were treated with respect, were able to make decisions about their lives and take risks as part of an independent lifestyle. EVIDENCE: Two people were case tracked; this means their plans of care were looked at in detail and other care records examined, to ensure all their needs were identified and met. The care plans had identified needs and risk assessments in place ensuring people’s needs could be met. DS0000003120.V355672.R01.S.doc Version 5.2 Page 10 From talking to staff and observing interactions between staff and people, it was clear staff did not fully understand some of their mental health needs. The manager was aware of this and had put measures in place to address this to ensure all people’s needs were met. The manager told us that they were also in the process of implementing new plans of care, which were person centred and focused on outcomes for the people. This would ensure all their needs were identified and met. Training for the new plans was taking place on the day of the visit. Once that was completed, the staff would start the new plans with the individuals, which will ensure all their needs are identified and met. People were supported to make decisions about their lives and take risks as part of an independent lifestyle. Assistance was given if required. People spoken to told us “The staff are really good they help us and look after us well”. All people who lived at the home had risk assessments for responsible risk taking whilst in the home. Assessments were also in place for leaving the home/holidays. People were supported to take risks as part of an independent lifestyle. Risk assessments were in place for smoking, and nobody was allowed to smoke in their bedrooms, however during the tour of the building it was evident that some people were still smoking in their bedrooms, this places other people who lived at the home and staff at risk. One person had actually damaged a new floor covering by smoking in their bedroom. The manager was aware of the need to stop this practice and was working with the staff and people to manage this and ensure the safety of people. DS0000003120.V355672.R01.S.doc Version 5.2 Page 11 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): 12, 13, 15, 16 & 17. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Activities provided were good; people accessed the local community and maintained family relationships. The home offered a healthy diet. EVIDENCE: Activities had much improved since the last visit. Thirty hours were allocated each week, many activities outside the home were organised. A vehicle was used regularly to take people out on various activities, either in a group or on a one to one basis to ensure their needs were met. People attended various day centres and rehabilitation centres and the people that went out on their own continued to do so. People told us “Activities are good now we have quizzes and baking”. DS0000003120.V355672.R01.S.doc Version 5.2 Page 12 The manager told us the activities organiser tended to take people out on activities and use the vehicle to meet people’s recreational needs. A carer also provided a number of activities in the home and organised quizzes, bingo, baking sessions and card games. These sessions were well received with many people attending and enjoying the activities. Holidays were being organised for all people who wished to have a holiday giving choices and ensuring people’s needs were met. Links with family and friends were encouraged and maintained, people spoken to said they were able to have visitors at any time and were able to see their relative in private if they wished. Some people who lived in the home also went out to see their family and friends. Meals had greatly improved, a good selection of food was available in the kitchen ensuring a healthy choice for the people. The shopping was now ordered online and delivered which meant care staff did not have to go shopping so they had more time to meet people’s needs. A cook had also been recruited to cook the main meal in the evening, which had further improved things. Care staff did not have to spend time in the kitchen cooking, taking them away from their main duties. Food choices seen were healthy, nutritious and balanced, people said, “Food is lovely, we have a choice and it is really nice”. DS0000003120.V355672.R01.S.doc Version 5.2 Page 13 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 adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People receive support in the way they prefer; their physical and emotional needs are mostly met. Medication policies and procedures are in place but do not safeguard people. EVIDENCE: Most health care needs of people were met and the new manager was still improving this. Regular input from health care professionals was now obtained. Their advice was followed and well documented in the plans ensuring the wellbeing of the people who lived in the home. Two health care professionals completed a questionnaire, the comments were very positive. One said, “Advice is always asked and the manager is very good at liaising with me regarding mental health needs of my client”. DS0000003120.V355672.R01.S.doc Version 5.2 Page 14 Some staff did not understand the mental health needs of the people, however the manager was addressing this through training to ensure all the needs could be met. All the people who lived at the home were registered with a GP Practice, and arrangements are in place for Chiropody, Ophthalmic and Dental services in order that their needs are met. None of the people in the home were self–medicating. All medication was stored in one unit, all the people at the home come to the staff office to receive their medication. We identified a number of medication errors, these had previously been identified at the last visit by the pharmacy inspector. The procedures seen did not safeguard the people. A large number of medications were hand written and had not been signed, not all medication was checked in and signed; medication was still in the blister packs but had been signed for as if administered. Medication had been increased on the medication administration sheet by care staff but there was no evidence in plans of care as to why or if this had been instructed by the GP. The errors identified would make the outcome for the people poor, however, following discussion with the manager and area manager, they have introduced measures to safeguard the people and prevent errors occurring. They have informed us in writing of the following measures. • • • A Deputy manager had been seconded from another home to oversee the medication. Two senior carers have been suspended from administering medication, as they were not competent. Two carers have been trained in medication administration, they have passed competency assessments and are now administering the medication. Medication files were to be checked on a daily basis by the manager and deputy. Medication files have been reviewed and improved for additional safety. • • DS0000003120.V355672.R01.S.doc Version 5.2 Page 15 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 outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. People’s views are listened to but not always addressed. People were protected from abuse. EVIDENCE: There was a comprehensive complaints procedure, which the manager told us would be clearly displayed, in the entrance hall in each unit once the renovation work was complete. All people we spoke to were aware of the procedure and the questionnaires returned told us that people were aware of how to make a complaint. They would either speak directly with staff or the manager. The manager had received a number of concerns which had all been resolved, good records were kept of outcomes. This showed they had been fully investigated, acted on and taken seriously. However a couple of questionnaires returned told us that people were not always aware their complaints had been dealt with and felt staff were not listening to them. All staff had received training in adult safeguarding. All staff we spoke to had a good knowledge of the procedures and what to do should an incident occur. Staff were also aware of the whistle blowing policy, which safeguards people in the home. DS0000003120.V355672.R01.S.doc Version 5.2 Page 16 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 & 30. People who use the service experience adequate outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. The standard of cleanliness was good and the environmental standards were improving. EVIDENCE: Major refurbishment was taking place at the time of the visit. Most bedrooms had been completed and all rooms were to be re-decorated providing a well maintained environment for the people. New furniture had also been ordered for the communal rooms, new settees, chairs and tables. New curtains and carpets were being provided in all areas. When all work is completed, the environment will be well maintained to a high standard for people. The standard of cleanliness had much improved from the previous visit, additional cleaning hours had been allocated and this was ensuring a clean environment was provided for the people. DS0000003120.V355672.R01.S.doc Version 5.2 Page 17 The grounds were also being landscaped. This will provide a large patio area with a water feature and seating for the people to be able to enjoy the outside space in the summer. The gardens were due to be completed at the end of March 2008 and the redecoration of all the rooms was due to be finished by end of April 2008. The people were very excited about all the work that was taking place, one person showed us her room and said, “it has all been redecorated, I chose the colours and the floor, and I am really pleased with it”. DS0000003120.V355672.R01.S.doc Version 5.2 Page 18 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, 34 & 35. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Staff were, in the main, appropriately trained, the recruitment procedures were robust ensuring people were in safe hands at all times, had their needs met and were protected. EVIDENCE: Care staff numbers were determined by the needs of the people and appropriate levels were maintained on the day we visited ensuring people’s needs were met. However, the manager had identified that people’s needs could be better met if a staff member was in each house. This is to be implemented once the works have been completed. Staff told us, “Things are improving slowly but morale is still low, due to lack of a staff structure, the manager is working very hard to improve things but she cannot be everywhere”. DS0000003120.V355672.R01.S.doc Version 5.2 Page 19 Staff also told us, “There is no recognition for being a senior carer and for the extra responsibility you may as well stay as a carer”. Since the visit we have been informed a deputy manager has been seconded from another home and two new senior carers appointed. This should improve staff morale and ensure people’s needs are met. All mandatory training was up to date, the company had robust systems in place to ensure this remained up to date for all staff ensuring people were in safe hands at all times. During the visit, talking to staff and observing staff interacting with people, it was evident that not all staff had a full understanding of people’s mental health needs, so needs were not always met. Training is to be organised regarding this by the manager to ensure people’s needs are met. A thorough recruitment procedure was in place, two staff files were seen on the day of the visit and contained all the required information protecting people who lived there. DS0000003120.V355672.R01.S.doc Version 5.2 Page 20 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 & 42. People who use the service experience good outcomes in this area. We have made this judgement using a range of evidence, including a visit to this service. Management and administration of the home was improving to safeguard people, good health and safety policies and procedures were in place ensuring the safety of people in the home. EVIDENCE: The manager was qualified and experienced to run the home. She had registered with the Commission for Social Care Inspection. She was also registered on the registered managers award and continually kept herself updated. This ensured the hom’es stated purpose, aims and objectives were met. DS0000003120.V355672.R01.S.doc Version 5.2 Page 21 Quality monitoring was carried out, the manager did regular audits and the provider carried out regulation 26 visits, these are visits to gain feedback from staff and people living at the home and relatives. The provider would also look at the environment and care plans and other documentation, which may be relevant. The home had a comprehensive health and safety policy. There was a new maintenance person in post and we were able to evidence that regular maintenance of equipment and systems was carried out. Risk assessments were carried out on all safe-working practices, regular audits were carried out on the building and all accidents were properly recorded and reported ensuring people in the home were safeguarded. DS0000003120.V355672.R01.S.doc Version 5.2 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for 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 X 4 X 5 X INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 2 23 3 ENVIRONMENT Standard No Score 24 2 25 X 26 X 27 X 28 X 29 X 30 3 STAFFING Standard No Score 31 X 32 3 33 X 34 3 35 3 36 X CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 2 3 X 3 X LIFESTYLES Standard No Score 11 X 12 3 13 3 14 X 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 1 X 3 X 3 X X 3 X DS0000003120.V355672.R01.S.doc Version 5.2 Page 23 Are there any outstanding requirements from the last inspection? Yes 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 YA24 Regulation 23 Requirement The registered person must ensure that the homes premises are suitable for its stated purpose. Accessible, safe and well maintained. (Old timescale 01/10/07) 2. YA9 12 The health safety and welfare of all people in the home with reference to smoking in their bedrooms, and other nondesignated areas, must be safeguarded. 01/04/08 Timescale for action 01/05/08 3. YA20 13 (Old timescales 15/7/06 and 01/08/07) The documentation of medication 01/04/08 must be improved to safeguard people. All medication must be recorded if not given and reasons why. Checked and signed for on receipt. The amount of tablets left at the end of the month must be transferred from one Medication administration sheet to the next. (Old timescale 01/08/07) DS0000003120.V355672.R01.S.doc Version 5.2 Page 24 4. 5. YA22 YA6 22 15 People’s concerns and complaints must all be listed to ensure their needs are met. People’s metal health needs must be identified and met. 01/04/08 01/04/08 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 Refer to Standard YA20 YA20 It is recommended that a full medication audit be undertaken. Check staff competencies for administration of medication and re-train where necessary. DS0000003120.V355672.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection North East Region 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 DS0000003120.V355672.R01.S.doc Version 5.2 Page 26 - 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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