Inspection on 21/06/05 for Church View

This inspection was carried out on 21st June 2005.

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

The inspector 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 19/01/09

Church View 15/01/08

Church View 02/07/07

Church View 05/07/06

Church View 12/12/05

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 S61 1EW Lead Inspector Mike Hamstead Unannounced 21 June 2005 07:50 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationary 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 CS0000003120.V176382.R01.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Church View Address Church Street Kimberworth Rotherham South Yorkshire S611EW 01709 557658 01709 550541 churchview@craegmoor.co.uk Parkcare Homes (No 2) Limited Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) Post Vacant PC Care Home only 22 Category(ies) of MD Mental Disorder 22 registration, with number of places CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: To admit one named resident over the age of 65 Date of last inspection 30 November 2004 Brief Description of the Service: Church View is a care home registered to provide care for 22 service users with a diagnosis of mental illness. The home provides 24 hour care for service users with enduring mental health needs, and encourages self sufficiency and self reliance where possible via a combination of staff support, and the teaching of independent living skills. i.e. budgeting skills, meal planning and preparation, and general life skills.The aim is to combine this with appropriate day care education and work experience, to encourage and foster social skills. Church View is organised into 3 separate houses, Vicarage, Canterbury, and York, all self contained, with single bedroom accommodation, bathroom/ wc facilities, and separate kitchen, dining room and lounge facilities in all of them.The service user group is predominantly male, there is only one female resident, and the age range is between 25 - 77 years of age, with the majority of service users being in the 35 - 50 age range category. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of interviews with the care manager and all staff on duty, and an examination of the progress made since the last inspection and homes records. It also included a tour of the building to observe the accommodation. Additional information of the overall situation had been gained from previous inspection visits. The inspection was commenced at 07:50 and finished at 16:15 and included talking to all members of staff and residents. What the service does well: Obtains an accurate assessment of residents needs including specialist needs, and prepares a plan of care and develops this based upon the experience and changing needs of residents living there. Enables residents to be involved in the day to day running of the home, and to be involved in decision making to the level of their interest and capability. Provides a flexible approach to daily living activities and proceeds at the residents own pace with opportunities for residents to become involved in the local community. A range of both vocational opportunities and leisure pursuits are available for residents to choose from, including an annual holiday. Provides sufficient staff to meet residents needs, and has a comprehensive staff training programme. Ensures that residents views are listened to, and where necessary acts to safeguard their safety at all times. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 6 What has improved since the last inspection? What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 2 3 4 & 5 Potential residents/representatives have all the information about the home available to them to enable them to understand and decide whether the services the home provide meet their needs. A small number of residents needs are not being met at the present time. Opportunities are provided for residents/representatives to visit the home prior to admission so that they can familiarise themselves with their potential surroundings and meet other residents and staff before deciding whether they want to live at the home. EVIDENCE: New residents are admitted following an assessment of needs by both the placing authority and the home, which also usually includes a Care Programme Approach assessment, and all residents receive specialised input for their mental health needs. There have been 4 new residents admitted since the last inspection. The care manager is aware of the assessment requirements outlined in this standard, and ensures that these are followed for all new admissions. All residents have had revised assessments since the last inspection, and the care manager is of the opinion that 3 possibly 4 residents are not having their needs met in full and she has sought reassessments for them. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 9 Efforts by the care manager and her staff has resulted in the availability of additional care co-ordinators/social workers and CPN’s and assertive outreach workers, that has led to an increased level of contact with residents generally, and for many residents this has meant opportunities to have their needs and aspirations met at day care, back to work courses, and college courses. All residents are requested to visit the home, prior to admission, and the majority do so, including the 4 new admissions who all came for day visits and had a meal with other residents and staff. These residents were told that they could visit as often as they liked until they were ready to make a decision as to whether they wanted to move in permanently. All residents are issued with a contract, and there is a minimum three months settling in period offered for long - term placements. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 10 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 6 7 8 9 & 10 The individual needs and choices of most residents are being met demonstrating the availability of an accurate and ongoing assessment of the majority of residents. EVIDENCE: All plans of care are up to date, and the systematic re-assessment of residents needs by the care manager and line management using their own assessment tool, has enabled them to identify the basis of these plans of care. All plans of care are still being reviewed via the CPA programme, on a 6 monthly basis and residents are consequently seen and reviewed by consultants on a regular basis that usually takes place at Cornerstones in Rotherham. The rights of service users to make their own decisions is paramount, and where mental illness is the primary diagnosis, such decisions can fluctuate on a frequent basis, requiring caring skills of the highest order in order to deal with regular and conflicting demands from them. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 11 None of the residents has a visiting advocate, but rely on advice from staff, and visits from professionals, who visit amongst other reasons to give depot injections. Whilst it is evident that the home provides more opportunities for more residents to become involved with, for some other residents, their continuing mental ill health combined with a history of inactivity in the home, appears to have resulted in a general inertia amongst them, and a lack of motivation to become involved in anything other than the basic tasks of daily living. Some residents have varied interests and hobbies they would like to pursue further, e.g., computers, craft, and painting, and these are provided by the home via staff fund raising activities. Some residents were sitting under a gazebo on the day of the inspection, also provided by fund raising within the home. Five service users manage their own money, whilst others are less skilled at budgeting and are happy to draw amounts on a daily basis, whilst yet others are happy to allow their money to be managed by staff in the home. Regular residents meetings are held that are minuted, where residents are invited to give their views on a variety of topics including ideas for activities, and the homes policies and procedures are made available for residents but little interest has been shown to date. Residents meet potential staff when they visit the home, but are not yet involved in their selection. A resident’s satisfaction questionnaire has been introduced, which will enable staff to act upon any issues raised by residents in the home. All residents have risk assessments for responsible risk taking whilst in the home, and also for leaving the premises and for holidays. One resident is risk assessed for visits home to his family, another for his excessive drinking. Staff request the assistance of CPN’s in the risk assessment process and risk assessments are included in the plans of care, and are reviewed by care staff. Staff continue to have risk assessments for smoking and there is a notice warning of the dangers in every bedroom. In addition, staff have drawn up a smoking “contract” with residents which states that all damage has to be paid for, and that residents may be asked to leave the home if they are found to be smoking in their bedrooms or communal lounges. Each unit has a smoking room, but there is still evidence that some residents smoke in the communal lounges, and the kitchen that endangers other residents and staff and must cease. It is clear that the homes management is acting to prevent a potential serious fire situation in the home, and must continue to enforce the smoking CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 12 “contract” because of its obvious effect on the health and safety of all residents and staff in the home. There is a policy on confidentiality, and all records containing resident information are kept safe and secure and are locked. The plan of care and daily working notes have now been separated from the main file, and are available to staff in each of the three houses. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 13 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 11 12 13 14 15 16 & 17. Most residents are able to maintain appropriate and fulfilling lifestyles both in and outside the home. There are now increased opportunities for personal development, education and occupation, and community links are promoted. Regular communal and leisure activities are available, and contact with family and friends is encouraged and maintained to enable residents to engage in appropriate relationships. EVIDENCE: There are more opportunities for residents personal development now that care co-ordinators and assertive outreach workers have become interested and involved in this aspect of resident welfare, and there is evidence to this effect. It is now becoming possible to co-ordinate a wider range of planned activities by staff in the home alongside the official/agency arranged facilities to provide a package of outcome based activities based upon residents leading ordinary and meaningful lives appropriate to their peer group. All residents are encouraged to become involved in training days to improve their independent living skills and some residents assist with gardening, and are hoping to make CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 14 bird tables supervised by the maintenance man. There are trips to Meadowhall and shopping trips, but there is still a wide disparity in financial support received by different residents, and many of them still have insufficient money from their income support and DLA to enable them to pursue any reasonable kind of personal event/activities even if they wanted to. The care manager is pursuing this aspect, and all residents are to receive a financial reassessment because of this discrepancy. One resident attends the local St Thomas’s church, and another service user attends church with his mother on occasions. There appears to be a renewed interest in residents wanting some form of employment or educational training, partly as a result of new residents being admitted to the home, and one resident has been accepted on a back to work course and is awaiting a starting date and two other residents have indicated that they would like to follow this option. Three other residents are on courses, one a computer course at Swallownest another an English course also at Swallownest, and this resident is hoping to have a selection of his own poems published, whilst another resident has started a music course at Rotherham College of Arts and Technology. Four other residents attend day centres/rehabilitation centres in Rotherham, and these are all examples of the progress that can be made with a coordinated effort by the home and agencies involvement to provide valued or fulfilling activities for residents and is a vast improvement from the last inspection. Other residents are proceeding at their own pace in liaison with staff and agencies whilst a small nucleus of longer stay residents are still proving difficult to motivate at all. Residents are encouraged to broaden their horizons, and some go out of the home on their own to the post office, library, the supermarket, the pub, and on organised outings by the home. All residents have a bus pass, which enables them to ride more cheaply, but not for free, and the home has a shared 8 seater mini-bus, and a car, and is shortly to have its own exclusive mini-bus. Four residents voted at the recent general election demonstrating their community involvement. Four residents enjoyed a holiday in Blackpool in May this year and another trip is planned for the illuminations in October. As in previous years, there are some residents who are not interested in a holiday, and this is recorded. One service user goes independently on the train to various places, and mentioned that he had made his own way to Matlock on the train recently CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 15 changing at Derby. Residents are encouraged to maintain family links, and there was clear evidence of peer relationships within the home. Residents use the communal areas, within their own house, and can, and do visit other residents in other houses, as well as making visits to the office, for information, money, or simply social contact. Staff try to encourage residents to eat a healthy diet, which is proving difficult with some of them, and residents are now involved in menu preparation which is based upon a 4 weekly cycle, where residents from one house take turns to plan the menu for all the houses. Two residents commented that on occasions dependent upon which staff were on duty the food was not very good and was repetitive without any choice. The care manager is to investigate this allegation to make sure that the food provided is wholesome and nutritious at all times. There was evidence that birthdays and special occasions are celebrated at mealtimes. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 16 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 19 20 & 21 The promotion of personal healthcare and specialist support to residents is taken seriously and acted upon to safeguard their interests at all times. EVIDENCE: All residents receive personal and emotional support, from staff in the home as required via a key-worker system, and there is nobody with a physical disability at the present time. Intimate care if required is carried out in privacy. Whilst the majority of residents can rise or retire to suit themselves, some residents require prompting to get up, otherwise according to staff some would stop in bed all day if allowed to. One resident is currently attended by the District Nurse because of a continuing episode of self - injurious behaviour, and most residents will inform staff if they are not well in the physical sense. Staff try to remain vigilant in order to recognise subtle changes in residents behaviour which may be the early warning signs of something more serious approaching resulting from their mental ill - health. Any such concerns are recorded and monitored, and include the prompt referral to an appropriate specialist if considered necessary. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 17 The majority of residents are registered with the local GP Practice, and arrangements are in place for Chiropody Ophthalmic and Dental services. None of the service users are self–medicating, and all residents have a lockable drawer in their bedrooms for personal possessions. Four residents are on Depot injections, which are given by a visiting CPN. The care manager has arranged it that all residents visit the Vicarage in a morning to have their medication administered, which provides a motivation for them to get out of bed, and then breakfast is served for them all in the Vicarage dining room, where they are able to socialise with other residents. There is a medication profile for every service user explaining the likely side effects of their medication, and all staff administering medication have now received accredited training, A sample of MAR sheets were examined and stock levels checked and found to be satisfactory. Controlled drugs are being witnessed by another member of staff and these were also found to be satisfactory. There is a policy on the ageing, illness and death of a resident and staff are aware of the importance of dealing with these issues with sensitivity and respect. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 18 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 22 & 23 Staff now have a greater knowledge and an understanding of how to identify and record residents complaints to ensure that their concerns receive attention and are dealt with appropriately. EVIDENCE: There is a complaints policy and procedure and a complaints record, and every resident has a copy, together with a copy of the Whistle Blowing policy. There has been one anonymous complaint since the last inspection that has been investigated and dealt with for the benefit of all residents. The care manager has addressed the issue of complaints at a staff meeting to ensure that all staff are vigilant in recognising and recording when actual complaints are being made by residents in order that their concerns can be dealt with. There is a policy and procedure on Adult Protection and, and there have been no Adult Protection incidents since the last inspection. The residents financial affairs are promoted via a policy and procedure, and the monies of two residents were checked and found to be accurate. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 19 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 24 25 26 27 28 29 & 30 Continuing investment generally maintains the appearance of the home and creates a homely and comfortable environment for residents visitors and staff. There is a need for ongoing maintenance and general housekeeping to maintain the home in good order. EVIDENCE: The home is split into 3 separate units, in separate buildings, and meets the spatial requirements of this standard having been measured prior to the 1st April 2002. The premises appear safe apart from the danger posed by some residents continuing to smoke in the home. The premises are close to shops and local transport. Each house has its own lounge/dining room and separate kitchen facilities. Any private consultations are usually carried out in the residents own bedroom, or the office. The refurbishment in Vicarage House is now complete and the staircase and corridors have been recarpeted which is a great improvement. The kitchen has also been refurbished and there are plans for a new laundry. Two doors CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 20 however in this area were wedged against Fire Service advice and this practice must cease if the welfare and safety of all residents is to be promoted. In addition, there are plans to refurbish the bathrooms in Canterbury and York houses on the ground floor, and update the bathrooms on the first floor of both houses. The kitchens in Canterbury and York houses have been redecorated, but the kitchen and bathroom floor surfaces are looking quite shoddy, and must receive attention. All residents have a single bedroom, and all bedrooms meet the spatial requirements of this standard. All 3 separate units have their own bathroom/toilet, kitchen and lounge facilities. Most of the bedrooms still do not comply with the additional furnishing requirements of this standard but the care manager has asked all the residents what they would like in terms of the extra furnishings, and recorded in the plans of care those instances where residents have indicated they do not want specific items. One resident for example does not want a wardrobe that is linked to his mental ill health, preferring to have his clothes on a rail. Externally, there is seating provision on the verandas outside two of the houses, and grassy areas at the front, rear and side of the home, for use if required. Factors needing attention are that there are two old refrigerators awaiting disposal that are unsightly, the grass on the boundaries of the properties needs attention, and there are gathered leaves around the perimeter of the houses that need clearing away. The home is currently at full occupancy level, and as a pre-existing care home meets the standard provision of bathrooms and toilets in the separate units at the present time, although it is understood that there are plans to apply for a variation in Vicarage House that may have implications for the number of bathrooms and toilets required. There is a policy and procedure on infection control, and the home was found to be free from odours on this inspection. The situation of the home currently having a washing machine in the kitchen in every house in the home, where there is a possibility that soiled materials/clothing may laundered, will be resolved in the major refurbishment when a new laundry room is to be built. In the meantime, it is essential that any soiled laundry be treated with all the appropriate hygienic measures, to minimise the possibility of infection. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 21 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 35 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31 32 33 34 35 & 36 There is a stable and competent staff team in sufficient numbers who receive regular updated training to meet residents needs. EVIDENCE: All staff have job descriptions and clearly defined roles in respect of caring for residents with a mental illness. The care manager arranged in – house training for staff, on the different forms of mental heath, and its effects and how it can present in different residents, and this was presented by 3 CPN’s earlier this year, and was attended by all staff. Staff have the opportunity to ask about any aspect of their practice at any time and in supervision sessions that are up to date. Staffing deployment is at the level of one senior carer and 3 care staff per shift throughout the waking day. In addition there are 2 waking night staff on duty. All staff stressed the importance of maintaining this level of staffing in order to provide adequate levels of care to residents. There were 21 residents accommodated at this inspection with 1 resident in hospital for assessment. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 22 The home currently has a staff achievement level of just over 50 at NVQ Level 2, a factor that together with other training enables them to meet the assessed needs of residents. There are 22 care staff employed on a permanent contract split between seniors in charge of a shift, and other care staff. In addition the home employs an administrator, 3 domestic persons, and 1 maintenance man. The staffing complement is determined by the number of residents and their dependency levels, but is never less than 2 per shift, as was agreed by RMBC R&I inspection Unit prior to the 1st April 2002. There is still only 1 female service user in the home, and the staff team reflects the gender composition of service users. There is a recruitment policy and procedure, and the files of three staff members employed since the last inspection in November 2004 were checked and found to be satisfactory. Residents are not currently involved in interviews for staff but are introduced to them when they look around the home. All staff receive a statement of terms and conditions in their contract of employment There is a Training and Development policy and a delegated budget, which is the responsibility of the care manager, and all staff receive induction training within their first week of employment, and also foundation training after 6 months. All staff receive equal opportunities and disability training as well as First Aid, Food Hygiene, COSHH, Moving/handling, and working with difficult clients training, and at least 5 training and development days per year. The presenting problems of residents, informs the home’s assessed training needs for staff, conducted as part of the homes appraisal system for staff. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 23 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 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 37 38 39 40 41 42 & 43 Residents benefit from a home run well and in their best interests, but certain aspects of their health and safety needs to be promoted further to safeguard their overall welfare. EVIDENCE: The care manager has a background in working in residential care, and has already been registered with CSCI as a care manager within a domiciliary care organisation in Rotherham, prior to moving to Church View. She has achieved NVQ Level 4 in management and care and is an SEN who qualified in 1980 in Doncaster. The care manager is due to attend for her “Fit Person” interview with CSCI in the next couple of weeks. All the staff spoken to felt that the care manager provided direction and leadership, and had an open door approach, enabling them to consult her with ease. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 24 The care manager carries out an audit of the homes operations on a monthly basis, followed by a visit from Operations Management from Craegmoor, as part of the company’s continuous self-monitoring role. The objectives of the home and its budget are reviewed 6 monthly, and there are also Reg 26 (2) (c) visits. Resident and relatives questionnaires are used, which are sent to Craegmoor management, for analysis, and the care manager said that she now receives feedback of any issues raised. Policies and procedures are reviewed periodically and updated to ensure they remain relevant to residents overall needs. Any resident interested, is able to look at the homes policies and their own files, that illustrates the open and inclusive approach adopted by the home towards resident participation in this area. There is a policy on safe working practices, and the health, safety, and welfare of residents and staff is promoted at all times by arranging the necessary training for staff examples include, the moving and handling of shopping, and any other item of equipment or furniture constituting a potential safety hazard. Fire safety training is undertaken, and an external trainer does the first aid training for staff. Food hygiene training is done on an annual basis, and infection control is done 2 yearly, via a distance learning course. The gas boilers were serviced yesterday by a corgi registered person, but it was still not possible to verify that the electrical check of the hard wiring had been carried out for once again the certificate was not available for inspection because it was at head office, and this must be rectified in order to safeguard residents and staff alike. Night staff check the water temperatures, and thermostatic valves have been fitted to all baths and hand wash basins to control the risk from hot water. The check for Legionella was carried out in May 2004, and PAT testing was carried out in February 2005. All first floor windows have window restrictors fitted, and these are checked weekly by the maintenance man. All potential risks from the domestic cookers and microwaves are assessed, and all doors have suitable locks for security purposes. All accidents are recorded, and there are safety procedures outlining the procedure to follow in the event of a fire. The fire records were found to be satisfactory. There is public liability insurance cover to April 2006, to safeguard all residents staff and visitors to the home. CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 25 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score x 3 2 3 3 Standard No 22 23 ENVIRONMENT Score 3 3 INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 LIFESTYLES Score 3 3 3 3 3 Score Standard No 24 25 26 27 28 29 30 STAFFING Score 2 3 3 3 3 3 3 Standard No 11 12 13 14 15 16 17 3 3 3 3 3 3 2 Standard No 31 32 33 34 35 36 Score 3 3 3 3 3 3 CONDUCT AND MANAGEMENT OF THE HOME PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 CHURCH VIEW Score 3 3 3 3 Standard No 37 38 39 40 41 42 43 Score 3 3 3 3 3 2 3 CS0000003120.V176382.R01.doc Version 1.30 Page 26 Yes Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard YA 3 YA 17 Regulation 14 16 Requirement The registered person must ensure that the home can meet all the residents assessed needs. The registered person must ensure that suitable wholesome and nutritious food is provided that is varied and properly prepared. The registered person must ensure that doors are not wedged against Fire Service advice. The registered person must ensure that attention is paid to floor surfaces within the home and that the external premises are tidied. The registered person, must produce evidence that the health and safety of all service users is being safeguarded, via the availability of appropriate certificates for inspection specifying that the work has been done. Timescale for action Immediate Immediate 3. YA 24 23 Immediate 4. YA 24 23 31/07/05 5. YA 42 23 Immediate CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 27 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. Refer to Standard Good Practice Recommendations CHURCH VIEW CS0000003120.V176382.R01.doc Version 1.30 Page 28 Commission for Social Care Inspection First Floor Barclay Court Heavens Walk Doncaster DN4 5HZ 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 CS0000003120.V176382.R01.doc Version 1.30 Page 29 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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