Inspection on 17/07/06 for Church View

This inspection was carried out on 17th July 2006.

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 there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Church View 02/12/09

Church View 25/09/07

Church View 24/10/05

Church View 09/06/05

Church View 01/11/04

Church View 19/04/04

Similar services:

Chirnside House

Keer Sands Residential Home

Ruskin Lodge

Bushell House

Langrigg House

Parkside

Dystlegh Grange

Thornton Lodge

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

CARE HOMES FOR OLDER PEOPLE Church View Green Lane Liverpool Merseyside L13 7EB Lead Inspector Julie King Unannounced Inspection 17th July 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church View Address Green Lane Liverpool Merseyside L13 7EB 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) 0151 228 0997 church.view@ashbourne-homes.co.uk Ashbourne (Eton) Limited Karen Witterick Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 7. 44 Nursing OP and 44 Personal Care OP within the overall number of 50 6 DE(E) Personal Care within the overall number of 50 One named service users under 65 year of age may be accommodated within the overall number of 44 Personal Care One personal care bed OP registered to accommodate one named service user with DE(E) One named service user under 65 years of age may be accommodated within the overall number of 44 nursing One (1) named female service user under 65 years of age (DE) to be accommodated in the 6 DE/E unit. One named person under 65 years of age for respite care Date of last inspection 24th October 2005 Brief Description of the Service: Church View care home is located in a suburb of Liverpool, close to all amenities including shops, cafes and a library. Bus and train stations are nearby. The home has ample car parking to the front of the home, and gardens to the rear. Registration via the CSCI includes, 44 nursing care beds, and six dementia residents who require personal care. All parts of the home are accessible to residents including the garden areas and upper floors via a lift. Communal lounges and dining rooms are furnished and decorated in a domestic homely way. Residents may take their meals in the dining rooms or in the privacy of their own room. Visitors are encouraged to visit at any reasonable time of day. Fees are currently local social service rates; privately arranged rates negotiated individually are for non-social funded service users. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. As part of a key inspection, this site visit took place over 7.5 hours, during which a full tour of the premises took place, staff and care records were examined. The inspector was accompanied throughout this visit by the manager whom gave input to the inspection. Some staff on duty plus some residents and relatives were spoken to during this visit. 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. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 6 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 7 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5,6. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home’s Statement of Purpose and Resident Guide provides enough information for prospective residents so they can be clear about the services the home provides to meet their care needs. EVIDENCE: The provider has a Statement of Purpose and Resident Guide to give prospective residents a reflection of the services and facilities provided at Church View. However both documents need updating to accurately reflect the home’s management structure and the recent change of ownership. All residents are issued with a contract / statement of terms and conditions on admission, which sets out responsibilities of all parties and what is included in fees, etc. Pre admission assessments provide a holistic assessment of actual and potential needs of each prospective resident; thus allowing a comprehensive care plan to be developed. However it was recommended that the pre Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 8 admission assessment tool is utilised in more detail to ensure that all prospective resident’s needs are fully identified. Multidisciplinary healthcare team (MDT) input is evident in resident’s care files, and include reference to NHS outpatient’s appointments, opticians, dentistry, and tissue viability nurse specialist (TVNS) input at the home when needed. Trial visits are offered to all prospective residents prior to admission – this is re-iterated in the Statement of Purpose and Service User Guide. It is suggested to the manager that all trial visits are clearly documented in appropriate care files if and when they take place. Church View does not offer intermediate care. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 9 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7,8,9,10,11. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a care planning system in place for all residents. This provides staff with the information they need to meet the resident’s needs. Medication storage was not compliant with requirements, thus potentially putting residents at risk. EVIDENCE: Recently admitted residents, and those requiring a high amount of care were case-tracked (followed from pre-admission into the home in all aspects to date), and spoken to in order to establish a holistic view of what that resident’s lifestyle is like at Church View. The residents said that they had had the opportunity to meet someone from the care home “for a chat” prior to admission; and that their families were involved. The commercially produced care plans are loosely based on the Roper, Logan and Tierney model of nursing care; and evidence input from the resident, their representative and the multidisciplinary healthcare team as needed. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 10 Monthly reviews and evaluations were evident on most care plans seen, and the plans were based on needs identified on the pre-admission assessments and multidisciplinary healthcare team (MDT) input was evident in all necessary care plans. However the standard of record keeping varied greatly depending upon which nurse of care assistant had completed the records. Also some of the care plans required updating with what was actually being recorded on the daily report records – this was discussed with the manager who assured the inspector that all necessary documentation would be updated as a priority. Medications were examined as part of this unannounced inspection, and in all aspects except the temperature of the medication room, was found to be satisfactory. The medication room temperature on the day of this site visit was 27°C. The maximum temperature most medications should be stored at is 25 degrees Celsius. Residents spoken to said they were “happy living here”, and “the staff are lovely”. Staff appear to have a good rapport with residents and their relatives, and were observed sitting talking to some of the residents and their relatives during the afternoon. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Links with the local community are good, and support and enrich the resident’s lives. Meals in Church View are good, offering choice and variety, and cater for resident’s special dietary needs. EVIDENCE: Residents in the home are asked on admission about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in, such as outings, bingo and manicure therapy. On admission to the home the resident with help from a family member completes an initial care plan, which includes a social history as well as referring to hobbies, food likes and dislikes information, etc. This information is used to plan organised activities for the resident. Visitors are allowed in the home at any reasonable time of day, residents may entertain their visitors in the communal lounges, or in their own bedroom. The gardens are accessible and tidy, and are an ideal setting for residents to sit with their relatives, especially in the summer months. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 12 Meals evidence a choice and variety, and special dietary needs (such as diabetes) are catered for. Records are kept for the recording of fridge, freezer and cooked food, and the kitchen was tidy and well maintained. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 13 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,17,18. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. A complaint and adult protection policy and procedure was in place that helps ensure the safety and welfare of residents. EVIDENCE: The residents, relatives and staff can access complaint policies and procedures as and if necessary. The procedures include information on ‘whistle-blowing’, in accordance with current Department of Health guidelines. The CSCI has not received any complaints about this service since the previous inspection. Most of the staff have, or are in the process of completing training in adult protection, with the remaining having training planned for the near future. However all staff do receive basic training in the protection of vulnerable adults during induction. Residents are enabled to exercise their right to vote, either via post or in person; and there is no religious or political persuasion in the home. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 19,20,21,22,23,24,25,26. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Most resident’s rooms are personalized, providing residents with a homely place to live. EVIDENCE: All areas of the home and most bedrooms were inspected. The majority of bedrooms were individualized according to the wishes of the resident, but some were in urgent need of redecoration / refurbishment and renewal of floor coverings. The bathroom on the top floor (room 291) is in urgent need of refurbishment, and some bedroom furniture, mainly on the top floor also requires replacement. Since the previous inspection there has been improvements to some bedrooms, the lounge and dining areas; and a designated smoking area was in the process of being finished in the main conservatory. There is very little storage space in this home, leading to items being stored inappropriately on Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 15 top of wardrobes, in corridors, in bathrooms and cluttering up communal areas. The registered person must give consideration to expanding the storage facility in this care home – this was highlighted in the previous inspection. The majority of the double glazed windows are in need of replacement as they have condensation within the sealed units. The inspector was informed that a refurbishment plan was in process, and these areas identified would be addressed. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27,28,29,30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There is a consistency of care within the home provided by permanent staff, which helps to offer safety and stability for the residents. EVIDENCE: A selection of staff personnel files were examined as part of the case-tracking process. Most files now contain all the required documents and records, but some are still in process of completion. CRB and POVA evidence was available, as were references, some training information, NVQ training, proof of identification and basic inductions. The manager was able to evidence that most of the staff have now completed mandatory training (training that is required by law to do the job), and some resident specific training (such as care of the resident who has Parkinson’s Disease, etc.) had taken place, with more planned. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 31,32,33,34,35,36,37,38. Quality in this area is good. This judgement has been made using available evidence including a visit to this service. Quality assurance is in place, thus helping to improve the quality of care given to residents. EVIDENCE: The manager has many years experience of her service user group, and is registered with the CSCI. Quality assurance is in place, with regular audits being evident. Residents and relatives’ comments are also being collated, and are assisting in further improvement of services provided at the care home. Staff spoken to stated that they had support, enjoyed their training and development experiences; and felt they benefited from having supervision sessions and appraisals. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 18 All of the records and documents seen evidenced regular updates, but a few requirements and recommendations were discussed with the manager, as listed at the end of this report. Certificates for fire, PAT (small appliance test), Gas safety, hoist and lifting equipment were up to date and valid. However the NICEIC (electrical safety) certificate was last issued in 2000 (valid for 5 years) so was expired and invalid. This lack of NICEIC requires immediate professional attention. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 2 3 3 3 3 N/a HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 10 3 11 3 DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 3 18 3 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 3 3 3 3 3 2 Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 20 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 OP1 Regulation 4&5 Requirement The registered person is required to produce a statement of purpose and service user guide, and keep them up to date at all times. The registered person is required to ensure that the service users care plan is kept up to date, valid and accurate at all times. The registered person is required to keep medications in accordance with requirements – refer to overheated medication room. The registered person must ensure that the environment is kept in a good state of repair at all times. The registered person must ensure that all furnishings are in a good state of repair. The registered person must ensure there is adequate and suitable storage space at the care home. The registered person must obtain and valid and up to date NICEIC (electrical Safety certificate) without delay; and DS0000059877.V296323.R01.S.doc Timescale for action 31/08/06 2 OP7 15 31/08/06 3 OP9 13.2 31/08/06 4 OP19 23 30/09/06 5 6 OP19 OP19 16 16 30/09/06 30/09/06 7 OP38 23 30/09/06 Church View Version 5.2 Page 21 forward to the CSCI a copy of this certificate once obtained. RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1 Refer to Standard OP3 Good Practice Recommendations It is strongly recommended that the registered manager regularly audits pre-admission assessments to ensure they are being used to their full potential and accurately reflect the needs of the residents. Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 22 Commission for Social Care Inspection Liverpool Satellite Office 3rd Floor Campbell Square 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Church View DS0000059877.V296323.R01.S.doc Version 5.2 Page 23 - 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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