Inspection on 25/09/07 for Church View

This inspection was carried out on 25th September 2007.

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

The inspector 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 17/07/06

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 Mrs Claire Lee Key Unannounced Inspection 09:30 25 and 26th September 2007 th 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.V347796.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.V347796.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 churchviewnh@schealthcare.co.uk www.southerncrosshealthcare.co.uk Ashbourne (Eton) Limited Care Home 50 Category(ies) of Old age, not falling within any other category registration, with number (50) of places Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. 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 Three un-named service users under the age of 65 years but no younger than 40 years of age may be accommodated within the overall number of 44 nursing. 17th July 2006 Date of last inspection Brief Description of the Service: Church View is a care home that provides care and support for up to forty four residents who require nursing or personal care and six who require personal care for dementia. Comfortable accommodation is provided over three floors with an attractively decorated lounge, dining room and conservatory for residents’ use. There is also a small separate lounge for residents who wish to smoke. The dementia unit has its own lounge with a small dining area. The home is situated close to all amenities including shops, cafes and a library. Bus and train stations are nearby. There is ample car parking to the front of the home and a garden which is easily accessible. Residents have access to a good standard of equipment to assist them with their mobility and a call system with an alarm facility is available throughout the home. The weekly fee rate for accommodation ranges from £315.50 to £505.00. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A site visit took place as part of the unannounced inspection. It was conducted over a two day period for a duration of approximately fourteen hours. Fortyfive residents were accommodated at this time. A partial tour of the premises took place and a number of care, staff and health and safety records were viewed. Discussion took place with twelve residents, five staff, and three relatives/friends. Southern Cross have appointed a new manager for the service as the existing manager resigned from her position in September 2007. The inspection was conducted with the proposed Registered Manager, Mrs Debra Rowan and the operations manager who was visiting during the second day of the site visit. During the inspection five residents were case tracked (their care files were examined and their views of the service were obtained). This process was not carried out to the detriment of other residents who also took part in the inspection process. All the key standards were inspected and also previous requirements and recommendations from the last inspection in July 2006 were discussed. Satisfaction survey forms “Have Your Say About …” were distributed to a number of residents, relatives, staff and health care professionals prior to and during the site visit. A number of comments included in the report are taken from the resident/relative survey forms and also from interviews. An AQAA (annual quality assurance assessment) was completed by the previous manager prior to the site visit. The AQAA comprises of two selfquestionnaires that focus on the outcomes for people. The self-assessment provides information as to how the manager and staff are meeting the needs of the current residents and a data set that gives basic facts and figures about the service, including staff numbers and training. What the service does well: The atmosphere was pleasant and friendly and residents appeared relaxed and comfortable with the staff. Good communication was evident and staff were chatting with visitors and offering them refreshments. Different aspects of care was seen to be given in a professional and discreet manner and residents were not hurried or their privacy compromised in any way. A resident reported, “the staff are very nice and helpful”. Residents’ care needs had been assessed prior to arriving at the home to ensure staff can provide the necessary care and support. This is followed up Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 6 with a comprehensive plan of care and risk assessments. The risk assessments identified any potential risk to the resident and the preventative and control measures implemented to ensure residents can achieve maximum independence with the support of the staff. The care plans were detailed and subject to review to ensure care needs were reflected accurately and fully met by the staff. It was evident through interviews, general observations and discussions that staff had a good knowledge of the residents’ individual care needs and the level of support they required. Evidence was seen of a resident receiving the clinical support from an external professional at the appropriate time. A resident said, “The care I get is good”. The manager and staff demonstrated an awareness and understanding of promoting positive outcomes for the residents, taking into account, for example, their age, gender, medical condition and belief. Care plans seen evidenced this information to ensure residents can continue with their preferred lifestyle according to individual need. An activities organiser oversees the social arrangements for the residents. Interests and preferred activities are recorded on admission and also when organised. This helps staff to monitor resident participation and enjoyment. Residents confirmed that ‘something’ is arranged most days. Staff are provided with training in safe working practices to ensure they have the skills and knowledge to undertake their work. Police checks and references are also sought prior to recruiting new staff to ensure residents are safe and not placed at risk. Quality assurance systems are in place to monitor the service and the manager and staff are working hard to continuously improve the overall care provision and ensure effective communication. This ensures a good quality of life for the residents. A stable workforce and also senior management within Southern Cross support the manager in her role. Health and safety policies and procedure are in place and equipment is well maintained to ensure the ongoing protection of the residents and staff. What has improved since the last inspection? The following requirements have been met from the last inspection: • • • The Statement of Purpose and Service User Guide as been updated to ensure it reflects the service provision. Resident care plans were found to be up to date to reflect current health care needs. The temperature of the clinical room, which is used for the storage of the medicine trolley, was found to be satisfactory. Temperature records had been maintained daily to evidence this. DS0000059877.V347796.R01.S.doc Version 5.2 Page 7 Church View • • Decoration of the premises is now being implemented and the staircase and landings were being painted at the time of the site visit. New furniture has been purchased for the lounges and also for a number of bedrooms. This will ensure maximum comfort for the residents. New carpets have also been laid in the main lounge and conservatory. Items were noted to be stored appropriately and not found in bathrooms or in the lounges. Wheelchairs were stored under the stair well. The electrical certificate for the premises was valid to ensure the safety of the residents and staff. • • What they could do better: The manager, Mrs Debra Rowan is to apply to the Commission for Social Care Inspection for the position of registered manager. A number of good practice recommendations are made in the main report to help improve the service and implement best practice. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 8 Please contact the provider for advice of actions taken in response to this inspection. The report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. The summary of this inspection report can be made available in other formats on request. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 9 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.V347796.R01.S.doc Version 5.2 Page 10 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 1,2 and 3 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents are provided with information regarding the service and pre admission assessments ensure staff can meet residents’ health and social care needs. EVIDENCE: The Service User Guide has been updated with the new manager’s details and the manager stated that this is made available for prospective residents and their relatives/representatives. Copies of the documents were seen in resident bedrooms. There was also plenty of information regarding the service in the main reception area and entrance hall for people to view. The Service User Guide provides comprehensive information regarding the service to enable residents to make informed choices. Photographs of staff were displayed in the main entrance help residents and staff to get to know everyone. Once a resident has taken up residency contracts are issued and these state the terms and conditions of residency and information regarding the care provision. Those seen had been signed by the resident and/or representative but were not dated or witnessed by a staff member to ensure their validity. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 11 The manager is not a registered nurse and therefore the nurses complete the initial assessment or accompany the manager to assist with the assessment process. Assessments seen were for residents admitted since the last inspection and these had been completed to a good standard. The assessment document identified key areas including medication, dependencies, pressure areas, nutrition, mobility, personal hygiene, medical history, continence, risk of falls, social/family background, communication, bedroom comfort and mental state. Residents had also been asked about their sight, hearing, chiropody and dental needs, which are so important to the care of the older person. A separate assessment is completed for residents with dementia care and this records in detail memory deficit in relation to every day tasks and lifestyle. The assessments help staff to collate the information for the plan of care and to assess any potential risk that may affect a resident’s welfare. Intermediate care is not provided at Church View and this standard was therefore not assessed. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 12 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 7,8,9 and 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents’ health care needs had been identified in a comprehensive plan of care and medicines were administered safely to them. Residents were observed to be treated in a respectful manner. EVIDENCE: Residents had individual care documentation and as part of the case tracking process five resident care files were viewed. The information was organised and available for staff and residents to view. Care documentation had been reviewed regularly to reflect changing needs and agreement to the care plan of care is now being sought. This is being carried out when the monthly care review is conducted as evidence of resident and/or relative involvement was missing in some care files seen. A number of risk assessments had been completed as part of the care planning process and these identified any potential risk that may affect a resident’s well being, in areas such as, nutrition, moving and handling and care of skin. Management of risks addresses safety issues whilst aiming for a better quality of life for the residents. Wound care was well managed with evidence of current treatments and progress of the affected area. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 13 Care plans are based on residents’ individual care needs including key areas such as mobility, communication, personal hygiene, continence and nutrition. A plan of care is also recorded for any relevant medical condition or for any specialist care or support needed. Pressure relieving equipment had been obtained for residents who spent long period in bed to minimise the risk of pressure sore development. Care needs for support with dementia were in place with associated risks for the effects of short term memory loss. Care plans seen gave good directions to staff to ensure continuity of care. A resident said, “The care is very good”. Residents are encouraged to be independent however the health care needs of residents who are unable to leave the home are managed by visits from GPs and other health care professionals. It was evident that residents had access to a full range of services. District nurse clinical input is obtained for residents who have personal care needs and require their advice. A resident said, “I see my doctor when I want and nothing is too much trouble”. Likewise a relative reported that the staff, “Always keep me informed if my next of kin is unwell”. Staff receive training in health care matters, for example catheter care and use of bed rails to which assist them with providing a good standard of care. Medications were well managed and staff receive training in medicine awareness to ensure medicines are administered and recorded correctly. Medicine charts viewed evidenced that medicines are administered as prescribed and medicines were found to be securely stored ensuring access is restricted to senior staff. Residents are able to administer their own medications if they wish and a risk assessment is completed by staff to ensure residents are able to undertake this practice safely. The manager carries out a check on the medicines each month and ensures staff are competent in medicine administration. Paperwork was seen to support this practice. This audit is essential to show that medicines are being handled correctly. Staff were observed to be polite and helpful towards the residents and care practices were undertaken in a discreet manner so as not to compromise resident dignity. Residents are asked their preferred name when they take up residency and staff spoken with were aware of the importance of promoting privacy and dignity within the work place. A resident said, “The girls are lovely and polite always”. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 14 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 12,13,14 and 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents can decide how they wish to spend their day and are offered well balanced nutritious meals. EVIDENCE: There was a pleasant atmosphere and residents appeared relaxed and comfortable with the staff. Visitors were seen at various time of the day and made welcome by staff. Residents can meet their visitors in their own rooms or in the communal areas if preferred. Residents confirmed that the routine was fine and that they could choose to go to bed at a time to suit them. Some residents prefer to stay in their own bedroom rather than using the lounge and this wish was seen to be respected by the staff. An activity plan for recreational activities was displayed. This included music, arts and crafts, listening, chair exercises and puzzles. An activities organiser is employed to provide this programme. Residents’ preferred interests and hobbies are recorded when admitted and a full social history is also completed at this time. Residents’ social participation is recorded daily to evidence their enjoyment. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 15 A tuck shop is available and residents can help with selling the various items. The manager is proposing a number of trips out from the home, which, will include pub lunches and shopping trips. Residents interviewed said they would like more activities arranged and the manager is keen to implement a more stimulating and structured programme. Members of the clergy visit to enable residents to continue to worship their chosen faith and Holy Communion is offered. A number of residents were going out with their relatives at the time of the site visit and sitting out in the garden. Staff on the dementia care unit were observed to spend time with the residents chatting about news items and family life. Activities are organised according to resident need and how the resident feels on the day. The menus were displayed in the dining room for residents to decide what they would like to eat and staff were seen to ask them if the meals were satisfactory and to their liking. Alternative foods are provided and residents are offered a good choice of well balanced meals. Preferred foods and dislikes are noted when residents are admitted thus ensuring they are served meals which they enjoy. A request for meals to be served hotter was passed to the manager for her attention. Food stores were satisfactory and there was plenty of fresh fruit and vegetables available. The dining room tables were attractively laid and there were flower arrangements on each table. Staff were observed to assist residents with the meals in an unhurried manner. Comments from residents regarding the food included: “Very good” “Nice meals” “The cook is good” “We like the food very much” “Meals are very good” Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 16 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 16 and 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Polices and procedures are in place to listen and respond to complaints and to safeguard and protect vulnerable people from abuse. EVIDENCE: The manager uses a complaint policy and procedure to investigate complaints and a summary of the complaint procedure was on display for residents to view. Residents interviewed were not all aware of content of the policy but stated that they would speak to the nurses if at all worried. A resident raised a concern at the time of the site visit and this was dealt with immediately by the manager and resolved. Complaints received had been recorded however the complaint log did not evidence sufficient detail regarding the nature of the complaints and the action taken when received. Since the last inspection the previous manager and also the Commission have recorded three complaints. One complaint was an adult protection issue, which was fully investigated by social services and the Commission. The complaint was partially upheld and management instigated training for staff to resolve the issues to the satisfaction of all parties. Prompt action was taken. There are currently no outstanding investigations. An abuse policy is available and staff have received training in the protection of vulnerable adults. A copy of Liverpool and Sefton’s Guide to the Protection of Vulnerable Adults could not be located and this should be obtained. Staff should be advised of the local document and referral to the local authority as Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 17 part of the safeguarding procedures for reporting an alleged incident. Staff interviewed were aware of the concept of abuse and how residents’ rights should be protected. This was discussed in relation to care needs, promoting independence and activities. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 18 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 19,20,21,22,24,25 and 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents live in comfortable, clean, and safe accommodation. EVIDENCE: Accommodation is based over three floors and subject to a maintenance and refurbishment programme to improve the overall standard of the building for the residents. A number of bedrooms have recently been decorated and also new bedroom furniture purchased; this was seen whilst touring the building. The manager is looking to replace more over the next few months. New carpets have been laid in the lounge and conservatory and new armchairs purchased for the comfort of the residents. The lounge and conservatory are pleasantly decorated and spacious. Areas seen whilst touring the building were bright, clean and there were no unpleasant odours. Residents and staff interviewed commented that the home now looked much better. A resident reported, “I like my room and do not want anything else”. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 19 Bedrooms were comfortably furnished and residents had brought in items from home to make their rooms personal. Call bells were available in the bedrooms to enable residents to call for assistance. The temperature of the hot water to the baths was being checked to ensure it was delivered to a safe temperature and emergency lighting was tested regularly as part of the safety checks for the building. This ensures the ongoing protection of people within the home. The bathrooms were clean and bath hoists installed to assist the residents with bathing. A walk in shower is planned for one bathroom, which will give residents a choice of bathing facilities. A hairdressing salon enables residents to enjoy having their hair done in comfort. Residents can have their meals in the dining room or in their rooms if preferred and there is a designated room for residents who wish to smoke. This room has been risk assessed as suitable for this purpose. A full maintenance plan was seen for the building and this should include decoration of the dementia care lounge as the walls and paintwork are scuffed due to general wear and tear. A new carpet and floor covering is on order for this room. On the dementia unit bedroom doors have letterboxes and doorknockers with resident photographs to help them feel at home and safe. The corridors have textured objects on the walls to provide stimulation. The staircase and landings were being painted at the time of the site visit and residents are involved with choosing new colours schemes for the home. The garden is well maintained and accessible for residents to enjoy sitting out. There is also car parking space. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 20 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 27,28,29 and 30 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Sufficient numbers of well trained staff provide care and support for the residents. Robust recruitment procedures ensure the ongoing protection of the residents. EVIDENCE: The staffing rota for the month of September 2007 evidenced sufficient number of staff on duty to provide care and support to the residents. Bank staff cover outstanding shifts as required. Staff spoken with however confirmed that resident dependency levels were high at present. In light of comments received the manager should conduct a dependency assessment of residents’ needs to help review the staffing numbers. This will help ensure staff have sufficient time to provide the care and support residents require. Residents interviewed were pleased with the attitude of the staff. Comments included: “Girls are polite and friendly” (resident) “The staff are around to help” (resident) “No problems with staff” (visitor) “Staff nice to talk to” (resident) “The girls are always pleasant” (relative) “The staff at the care home always have time for a laugh and joke with residents as well as families” Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 21 NVQ (National Vocational Qualification) training at Level 2 and 3 is ongoing for all staff. The manager should continue this training programme to provide a 50 ratio of care staff with this qualification. A selection of staff files were viewed and these included staff files for newly appointed staff. Two staff members have commenced employment since the last inspection and a stable workforce support the manager. Staff files evidenced completed job application forms, necessary police checks and two written references. Staff had been provided with a contract and job description. These details define the roles and responsibilities of the staff to assist them with their work. Effective recruitment procedures help ensure the delivery of a good quality service and protect the individual. New staff receive an induction and the Southern Cross induction record is in line with the Skills for Care Induction Standards. The induction is given over a period of time and staff interviewed confirmed that they received an induction when they started. Staff receive training in safe working practices to ensure staff have the knowledge and skill to provide care and support to the residents. Southern Cross operates a rolling programme for training. Eight members of staff are qualified first aiders and all staff have recently attended moving and handling training. Health and safety training and food hygiene training is also given. Staff interviewed confirmed that they attend regular courses and feel supported by management in their various roles. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 22 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. JUDGEMENT – we looked at outcomes for the following standard(s): Standards 31,32,33,35,37 and 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Church View is run in the best interests of the residents and they are protected by health and safety polices and procedures. A registered manager should be appointed. EVIDENCE: Southern Cross appointed a new manager for the service at the beginning of September 2007. Mrs Debra Rowan has held a previous manager’s post for the company and is undertaking the necessary qualifications in NVQ management to undertake this position. As part of the day-to-day management of the home the manager should be registered with the Commission. Mrs Rowan should apply to the Commission for this position. Since starting Mrs Rowan has improved the overall environment for the residents and has met with residents, relatives and health professionals to introduce herself. Comments received by health care professionals had Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 23 highlighted communication issues within the home however a visiting health care professional reported that staff communication and care practices had recently improved. Through discussion with the manager it was evident that Mrs Rowan had a clear understanding of the focus of the service and the need to provide good outcomes for people based on individual need. Staff, residents and visitors interviewed were very complimentary regarding her professional manner, ability to listen and enthusiasm for improving the service. An operations manager visits the home each week to support Mrs Rowan with her new role. The operations manger is also responsible for the completion of monthly visits to ensure the service is well run and to meet with residents and staff to obtain their views. Reports seen had been completed to a satisfactory standard. A resident said, “Debra (manager) is really good”. Likewise a staff member said, “Debra (manager) has made some really good changes and is easy to talk to”. There have no recent satisfactions surveys sent to residents and relatives and the operations manager stated that these were to be sent in October 2007. Results from the most recent surveys could not located however the operations manager confirmed that no issues had been identified when the surveys sere audited. Mrs Rowan had conducted resident and staff meetings and is looking to hold a social evening for relatives also. An evening surgery is held once a fortnight to enable Mrs Rowan to meet visitors who are unable to visit during the day. The manager is responsible for the completion of a number of audits for the service to ensure the residents are receiving a good standard of care. An audit was seen in relation to medicine management and care planning. Financial records kept on behalf of residents were up to date and kept in good order. This helps ensures ongoing financial protection for them. Formal supervision and staff appraisals with the staff are conducted and staff interviews confirmed that they could meet with management at any time to discuss any issues or training needs. The manager and staff have access to a good range of health and safety policies and procedures to ensure the ongoing protection of people who use the service. All policies and procedures are updated via the company’s intranet site to ensure they meet current legislation. Equality and diversity is addressed through a number of policies including equal opportunities for staff, sexual orientation, spiritual care, confidentiality, bullying and diversity. Assessments and care plans are person centred and identified physical, social and also sexual needs in relation to appearance, behaviour and religion. Staff had recorded accidents to residents and these are monitored to identify any pattern or contributing factor. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 24 A spot check was carried out for a number of maintenance contracts for safe working practices and equipment. These were found to be current. Fire alarms are checked weekly and staff receive fire prevention training. Fire prevention equipment is subject to an annual safety check and the fire risk assessment of the building is being updated to comply with the changes in the fire regulations. Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 25 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 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X 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 X 18 3 3 3 3 3 x 3 3 3 STAFFING Standard No Score 27 3 28 2 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x 3 3 X 3 Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 26 Are there any outstanding requirements from the last inspection? NO STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. Standard Regulation Requirement Timescale for action RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. 1. 2. 3. 4. 5. 6. 7. Refer to Standard OP2 OP7 OP16 OP18 OP19 Good Practice Recommendations Contracts should be dated and signed by the manager/and or member of staff on completion. Consent to the plan of care should be sought from the resident and/or their relative to ensure they are aware of the care provision and its review. Complaints received should be logged in detail to evidence the nature of the complaint and action to be taken. Liverpool and Sefton’s Guide to the Protection of Vulnerable Adults should be obtained for staff referral. The lounge on the dementia care unit should be painted and as the paintwork is scuffed due to general wear and tear. A minimum ratio of 50 of care staff should have a qualification in NVQ Level 2. A Registered Manager should be appointed for Church View. OP28 OP31 Church View DS0000059877.V347796.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Merseyside Area Office 2nd Floor, South Wing Burlington House Crosby Road North Waterloo L22 0LG 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. 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