Inspection on 24/10/05 for Church View

This inspection was carried out on 24th October 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 made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Church View 02/12/09

Church View 25/09/07

Church View 17/07/06

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 John McCabe Unannounced Inspection 24th October 2005 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.V260622.R01.S.doc Version 5.0 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.V260622.R01.S.doc Version 5.0 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.V260622.R01.S.doc Version 5.0 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 personal care bed OP registered to accommodate one named service user with DE(E) One named service users under 65 year of age may be accommodated within the overall number of 44 Personal Care 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 9th June 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. Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on the 24th October 2005, commencing at 0915 hours, the homes registered manager was present during the inspection. A senior first level nurse, and eight carers were on duty, supported by kitchen, laundry and domestic staff. The inspector spoke with residents, staff, reviewed care documents for residents, and the personal files for staff A full tour of the building was undertaken, including gardens, bedrooms kitchen and laundry. What the service does well: What has improved since the last inspection? The recruitment documentation for applicants wanting to work in the home has improved. Checklists are provided within the document’s to ensure all aspects of the prospective employees information is available to the home manager before a job offer is made and therefore this aids the recruitment of suitable staff. Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 6 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.V260622.R01.S.doc Version 5.0 Page 7 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.V260622.R01.S.doc Version 5.0 Page 8 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. The Homes Statements Purpose is up to date and provides prospective residents with sufficient information about the home, which helps them make an informed decision before they decide to move in on a permanent basis. The resident’s preadmission nursing/personal care assessment documentation is comprehensive; this ensures the care needs of the resident are identified as being able to be met within the home before admission. EVIDENCE: All residents in the home are provided with a statement of terms and conditions, plus a contract when they move in to the home on a permanent basis. Residents are able to visit the home or have an overnight stay before they move in on a permanent basis. The homes senior nurses undertake a nursing pre admission assessment on residents before they are admitted to the home, to ensure care needs can be Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 9 met. Other healthcare professionals known to the resident are involved in the completion of the document. The completed document is the basis of the residents care plan when admitted to the home and this guides staff in how to care for each resident. Care staff in the home undertake specialist care training, which is ongoing, to ensure that the assessed and changing care needs of the residents can be adequately met. Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 10 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. Resident’s individual health, personal and social care needs are not always clearly recorded, and at times this does not provide care staff with sufficient information to meet all of the residents care needs. Personal support in the home is offered in such a way as to promote and protect the resident’s privacy and dignity and independence. EVIDENCE: All residents in the home have an individual care plan, which is formulated on admission to the home, reviewed by the senior nurses on a monthly basis. Health records are documented daily for each resident, this includes any critical incidences plus any visits from GPs, specialist nurses etc. On the day of the inspection, there were no reported pressure area concerns for any resident. Most of the care staff have undertaken training on tissue viability and the Primary Care Trust (PCT) tissue viability nurse will visit the Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 11 home at any time if needs arise to advise staff and to ensure appropriate pressure area care is promoted. . One resident self medicates. This has been subject to risk assessment. Generally the nurses and senior carers in the home administer all medications for residents. The protocols for the receipt, storage, disposal, and documentation of medications in the home are in accordance with the National Minimum Standards (NMS). However, many of the residents Medical Administration Record Sheets (MARS), contained hand written scripts which were not accompanied by two signatures of trained staff. Also, residents PRN medications did not state the maximum dose in any 24 – hour period, staff on duty were informed of theses protocols. All residents in the home can access their NHS entitlement that includes access to GPS, dentist’s, chiropody services, and opticians. Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 12 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. Residents have choice and flexibility about how they spend their day in the home, and in pursuing leisure and educational activities according to their preferences. This encourages independence and individuality for each resident. Residents receive a balanced diet offering variety, which reflects the residents’ preferences. EVIDENCE: Residents in the home are asked on admission, about their lifestyle, food preferences, and choices about what social activities they would like to participate in. On admission to the home the resident with help from a family member completes a “Getting to know you” questionnaire, which is a “Work life History” of the resident, and includes past schooling, work, hobbies, food likes and dislikes etc. This information is used to facilitate organised activities for the resident. The home employs an activities coordinator, who has responsibility for organising social activities for the residents. Residents engage in bingo, sing a Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 13 longs, and a guest entertainer visits the home on a regular basis. On the 25th October some of the residents are going to Blackpool to see the illuminations. Visitors are allowed in the home at any reasonable time of day and residents may entertain their visitors, in the communal lounges, or in their own bedroom. The residents told the inspector that they enjoyed the variety of food in the home and were looking forward to ‘fish and chips and mushy peas.’ The main meal of the day is served early evening, as requested by the residents. The homes chef, is experienced and well organised as regards menus, menu planning, and has a good knowledge of the resident’s preferences for food. The kitchen space is large, clean, organised and well stocked with food. Most of the residents take their meals in the homes dining room. Special diets for residents with medical conditions can be provided for in the home. Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 14 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 The home has a satisfactory complaints system with evidence that residents feel their views are being listened to and acted upon. The homes policy and training programmes for POVA, and Whistle blowing, ensure that the homes residents are protected from any abuse. EVIDENCE: There have been no internal complaints, and no complaints were reported to the commission since the last inspection. Many of the residents used their postal vote in the most recent local elections. The care home has up to date information on the Protection of Vulnerable adults, this information is communicated to new employees on their induction course. On the day of the inspection there was evidence that many of the staff in the home had undertaken training on POVA protocols, and the Whistle Blowing Policy. Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 15 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. The standard of decor within this home is satisfactory with some evidence of continuing improvements, through maintenance and planning. The home does present as a homely, safe and comfortable environment for the residents. EVIDENCE: The care home environment is satisfactory; most areas of the home are clean, light, well decorated and well maintained. The gardens of the home are well maintained and tended, and offer peaceful, pleasant surroundings for the residents. However, some of the communal bathrooms still need to be refurbished, to bring them up to standard. Also one communal bathroom (number 29), resembles a storeroom. The room is littered with pieces of appliances, Zimmer frames; these must be removed to ensure safety of both residents and staff. Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 16 Liquid soaps and shampoos are still being left in communal bathrooms, even though the inspector has explained to most staff, the dangers these substances pose for residents with cognitive impairment, especially if they are ingested. Room 45 has a strong malodour, which is overwhelming, the carpet from the room should be removed and a suitable floor covering put down. Residents in the dementia unit have no secure garden area. They cannot access the main garden without being escorted by care staff. Space in the unit is very limited. Even the dining room, which acts as a room for activities, is overcrowded. Residents only have a poorly lit corridor to exercise, and walk freely. The lack of secure garden space and free access to the garden takes away the residents choice and freedom of movement. This is not in accordance with current practice of caring for residents with dementia via the Person Centred Dementia Care model. Corporate management of the home should consider providing secure garden space for the residents, or consider occupancy levels to the unit so more space is available for the dementia sufferers. The carpet in the resident’s main lounge needs to be replaced, and the walls decorated. The homes updated infection control policy includes the prevention and spread of Methicillin Resistant Staphylococcus Aureus and Hepatitis B. Residents told the inspector that parts of the home were cold, especially the conservatory. There is a mobile electric fire in the conservatory, but this often taken by care staff to somewhere else in the home. Corporate management of the home need to assess the homes heating capacity and make improvements where needed. During the tour of the homes kitchen, it was observed that the dishwasher had a fire hazard warning notice placed on it. The machine cannot be used and needs replacing or maintaining. Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 17 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. The standard of vetting and recruitment practices has improved with the appropriate checks being carried out on all new staff. This helps ensures that the residents are not put at risk. EVIDENCE: There is always a first level nurse on duty, who is assisted by care staff and ancillary staff. The homes recruitment policy is robust and in accordance with the National Minimum Standards (NMS). All staff in the home have an up to date CRB/POVA enhanced certificate, so helping to ensure the safety of the residents. The inspector evidenced the Personal Identification Numbers (PINS) of all the registered nurses in the home, which was documented on Nursing Midwifery Council (NMC) stationary. All PINS were in date and valid. Mandatory and specialist trainings for all staffs is ongoing in the home; i.e. diabetes, dementia, cognitive impairment. This was evidenced in the personal files of the staff. Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 18 Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 19 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. Staff morale is high in the care home, resulting in an enthusiastic workforce that works positively with residents to improve their whole quality of life. EVIDENCE: An experienced first level nurse with 17 years of home care, management, manages the home; the manger has successfully completed a NVQ Level 4 care management programme. Staff and residents told the inspector that, the home was run in an open, positive, transparent way, with both the staff and residents having regular meetings with the manager; the meetings are minuted and actioned upon. All staff in the home have documented supervision six times per year, this ensures that all staff have the opportunity to discuss with the manager and Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 20 other senior nurses, any issues, which can effect or improve the care for the residents. Documented supervision of all staff gives the staff and managers opportunities to discuss their own /or identified training needs. Where possible residents look after their own financial affairs as the home doesn’t hold any bank accounts for individual residents. The homes certificates of insurance and worthiness for machinery, gas, electricity, fire equipments, lift, hoists, Employers Liability were in date and valid. Both residents and staff files are kept secure in accordance with the Data Protection Act 1998. Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 21 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 3 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 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 3 Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 22 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 Standard OP19 Regulation 23 Requirement The registered person must ensure that the carpet in the main lounge is replaced and walls decorated The registered person must ensure that the homes dishwasher is replaced, or safely maintained The registered person must ensure that the carpet in room 45 is replaced with a suitable floor covering. The registered person must ensure that the hairdressers room is locked at all times when not in sue. The registered person must ensure that liquid soaps (shampoos) are not left in the communal bathrooms of the Dementia unit. The registered person must ensure that the heating in the homes conservatory is comfortable for the residents. Timescale for action 30/11/05 2 OP19 23 30/11/05 3 OP19 23 30/11/05 4 OP19 12 30/11/05 5 OP19 12 30/11/05 6 OP19 23 30/11/05 Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 23 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Church View DS0000059877.V260622.R01.S.doc Version 5.0 Page 24 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. 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