Inspection on 05/07/06 for Church View

This inspection was carried out on 5th July 2006.

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

The inspector found there to be outstanding requirements from the previous inspection report. These are things the inspector asked to be changed, but found they had not done. The inspector also made 2 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Church View 19/01/09

Church View 15/01/08

Church View 02/07/07

Church View 12/12/05

Church View 21/06/05

Church View 30/11/04

Church View 01/06/04

Similar services:

Whiteley House

Tyndale Avenue

2-10 Norfolk Road

Bennfield House Nursing Home

Eastfield Residential Home

Sign Health

Springwood

Fairburn Mews

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

CARE HOME ADULTS 18-65 Church View Church Street Kimberworth Rotherham South Yorkshire S61 1EW Lead Inspector Mike Hamstead Key Unannounced Inspection 5th July 2006 08:00 Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 2 This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Adults 18-65. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church View Address Church Street Kimberworth Rotherham South Yorkshire S61 1EW 01709 557658 01709 550541 NONE www.craegmoor.co.uk Parkcare Homes (No. 2) Limited 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) Dawn Wilkins Care Home 23 Category(ies) of Mental disorder, excluding learning disability or registration, with number dementia (23) of places Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. To admit one named resident over the age of 65 Date of last inspection 12th December 2005 Brief Description of the Service: Church View is a care home registered to provide care for 23 residents with a diagnosis of mental illness. The home provides 24 hour care for residents with enduring mental health needs. It encourages self sufficiency and self reliance where possible via a combination of staff support, and the teaching of independent living skills. 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 and community 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 resident group is predominantly male, there are only two female resident, and the age range is between 25 - 78 years of age, with the majority of residents being in the 35 – 50 age range category. Fees range from £310:00 - £1200:00 as at 1st April 2006 and additional charges are made for daily newspapers and magazines. The registered person makes information about the service available to residents and their families via the Statement of Purpose, and the Service User Guide. Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection methodology consisted of bringing together the cumulative information and evidence received at CSCI, available to the inspector since last inspection in December 2005, interviews with the people who use the service where possible, and interviews with the care manager and staff on duty. It also included an examination of the homes records, and a tour of the accommodation. There were 23 residents accommodated on this inspection. The inspection was commenced at 08:00 and finished at 15:15 and the inspector is grateful to all the residents, the care manager and staff who took part in this inspection. What the service does well: The home continues to undertake a thorough assessment of residents needs, and ensures that links with specialist agencies including hospital consultants and CPN’s are maintained. The home promotes the residents mental and general healthcare needs, and staff encourage resident independence within a framework of risk assessment. Residents are encouraged 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. The home 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. Relatives and friends are encouraged to visit the home and maintain important links with residents. A variety of wholesome and nutritious food to meet the differing tastes of residents is provided, and there is a relatively stable staff group who work together as a team, and have a good knowledge of the residents and their needs. Church View DS0000003120.V297940.R01.S.doc Version 5.2 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 DS0000003120.V297940.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 2 & 3. Quality in this outcome area is good, and this judgement has been made using the evidence available and a visit to the home. Residents now enjoy a greater level of contact and support from outside agencies. EVIDENCE: There has been one new resident admitted since the last inspection, and all 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, because all residents receive specialised input for their mental health needs. The home is full and there is a waiting list for admissions. The care manager is aware of the assessment requirements outlined in this standard, and ensures that these are followed for all new admissions. Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 9 The care manager and her staff have made great efforts in the last 18 months to increase the availability of resident support via arranging for additional care co-ordinators/social workers and CPN’s and assertive outreach workers, from the various agencies that has led to an increased level of contact with residents generally. This has meant that residents have had opportunities to have their needs and aspirations met at either day care centres, back to work courses, and college courses. One resident was getting ready to go to Rotherham to meet her outreach worker to go shopping and told the inspector that she “was looking forward to it” The care manager has acted quickly to involve the local agencies in the care of one out of area resident who had not received the necessary support from his placing authority upon admission. Church View DS0000003120.V297940.R01.S.doc Version 5.2 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 the following standard(s): 6, 7, & 9. Quality in this outcome area is adequate, and this judgement has been made using the evidence available and a visit to the home. Residents are encouraged to act independently within a framework of risk assessment, but smoking in inappropriate places endangers both residents and staff alike. EVIDENCE: The needs of residents are being constantly assessed by the care manager and staff using their own assessment tool, that has enabled them to identify residents needs and include these in plans of care. All but two residents are considered to be appropriately placed, and plans of care are still being reviewed via the CPA programme, on a 6 monthly basis. Residents are therefore consequently seen and reviewed by consultants on a regular basis that usually takes place at Cornerstones in Rotherham. There is a tendency for the company to change the care documentation on a frequent basis that is causing some confusion amongst staff and is resulting in there being obsolete documentation in some residents case files. Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 11 One resident that receives regular input from the community nurse has been reassessed as possibly needing permanent nursing care, and the care manager is awaiting the outcome, and another resident is hoping to move to a supported living situation in Rotherham because of the progress he has made. 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 to four residents, and one resident goes to Swallownest Hospital for this service. The care manager will consider advocacy services for one resident that has no contact with relatives or family when she considers he is able to tolerate the service. All staff have received training in dealing with the challenging behaviour of residents, and further mental health training is planned for staff to enable them to meet the residents needs. Many 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. Five residents 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, (last one 30/06/06) 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. Resident’s satisfaction questionnaire’s are organised by the company, that are then returned to them for analysis, and then sent to the home to 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. This resident was proud to inform the inspector that “he had not had a drink for two weeks” 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. Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 12 Staff also continue to have risk assessments for smoking, particularly in their bedrooms, 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. There is a smoking room in Canterbury unit, but despite regular room checks by staff there is still evidence that some residents smoke in their bedrooms that endangers other residents and staff and must cease. The Fire Officer continues to talk to residents about the dangers of them smoking in inappropriate places, and it is clear that the homes management is acting to prevent a potential serious fire situation in the home. This situation is a continual battle but must continue and the smoking contract must be enforced because of its obvious effect on the health and safety of all residents and staff in the home. Church View DS0000003120.V297940.R01.S.doc Version 5.2 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 the following standard(s): 12, 13, 14, 15, 16 & 17. Quality in this outcome area is good, and this judgement has been made using the evidence available and a visit to the home. Residents are provided with opportunities to maintain an appropriate lifestyle, subject to the financial disparity between them. EVIDENCE: The admission of some newer residents appears to have resulted in a general interest in residents wanting some form of day care attendance, educational training or employment. Many residents are on courses, that include, music, computers, poetry and painting. One resident has bought an electric organ and is taking lessons on it. Another resident attends a Woman’s group at Swallownest Hospital, whilst another likes to make model aeroplanes. One resident is hoping to work in the Mind canteen, and is currently taking a first aid course that is a pre-requisite for him obtaining the post. Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 14 Three other residents continue to attend day centres/rehabilitation centres in Rotherham, that provides valued and fulfilling activities for them and the care manager continues to seek additional places for suitable residents. There are a small nucleus of other longer stay residents who proceed at their own pace in liaison with staff and agencies, and are still proving difficult to motivate but this does not deter staff from continuing to try with them. Staff have managed to encourage one such resident to venture outside the home with support, and he now goes shopping with staff, and meets his assertive outreach worker. A continuing topic raised in many previous inspections concerns the 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. This discrepancy is difficult to understand, and the care manager is still pursuing this aspect with the residents CPN/Social workers. The spiritual needs of one resident are met by him attending the local St Thomas’s church, and 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 to the coast. Two residents had been on a trip to Cleethorpes on the day of the inspection accompanied by staff. All residents have a bus pass, that enables them to ride more cheaply, but not for free, and the home has a saloon car, but staff said that the loss of their mini-bus had placed restrictions on the general social activities in the home. and that hopefully they will shortly have their own exclusive mini-bus. The home held a summer fair, that was well attended by the local community, and raised a substantial amount of money for the homes activities fund. Five residents have enjoyed a 5 day holiday in Blackpool this year and other residents that did not want to go have been on day trips, and have benefited from the holiday fund in other ways that is recorded. One resident continues to travel independently on the train to various places that he chooses, and told the inspector that he had been to Knaresborough the previous day. Another five residents are due to go to Cleethorpes this weekend for 5 days with staff, staying in a static caravan. Residents are encouraged to maintain family links, and there was clear evidence of peer relationships within the home. A visiting relative spoken to said that after some initial problems, she felt the home was working well with her son, and that he appeared content. Two residents have formed a relationship, and staff have ensured that they have received appropriate advice. Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 15 All residents are expected to make their own beds and keep their rooms as clean as possible, but there is some reluctance by some residents to become involved. Staff are finding it a struggle to teach some residents independent living skills, with cooking and washing being problematic for most residents. All the residents bedrooms have lockable doors, and they are free to plan their day to suit themselves in terms of rising or retiring. Staff try to encourage residents to eat a healthy diet, that is not always successful, and residents are 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. There was evidence that birthdays and special occasions are celebrated at mealtimes, and there was a birthday party last week. During the world cup, there have been barbeques, and most residents have enjoyed this relaxed approach in the good weather. Church View DS0000003120.V297940.R01.S.doc Version 5.2 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 the following standard(s): 18, 19, 20, & 21. Quality in this outcome area is good, and this judgement has been made using the evidence available and a visit to the home. Attention is paid to the residents general physical and mental health care needs. EVIDENCE: The home operates a key-worker system, and personal and emotional support is offered to residents from staff in the home as required. One resident is showing some signs of frailty, and receives regular visits from the community nurse because of his self-injurious behaviour. This resident has recently been reassessed with a view to him being relocated, Staff said that whilst the majority of residents can rise or retire to suit themselves, some residents require prompting to get up, otherwise some would stop in bed all day if allowed to. Residents will generally inform staff if they are not well in the physical sense, and staff try 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 DS0000003120.V297940.R01.S.doc Version 5.2 Page 17 The majority of residents are registered with the local GP Practice, and arrangements are in place for Chiropody Ophthalmic and Dental services. There are two diabetic residents that are diet controlled, and one resident visits the clinic for her asthma. The nurse from the general practice visits to do an annual health check on all residents. None of the residents are self–medicating, but the care manager has arranged it that all residents visit the Vicarage unit 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 resident 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 found to be satisfactory. The Controlled drugs register was examined and stock levels checked that also proved to be satisfactory, and these are being witnessed by another member of staff as per the procedure. 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, should the situation occur. Church View DS0000003120.V297940.R01.S.doc Version 5.2 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 the following standard(s): 22, & 23. Quality in this outcome area is good, and this judgement has been made using the evidence available and a visit to the home. Residents are clearly aware that they can raise any issues that they are unhappy about, and that these will be listened to and acted upon. EVIDENCE: There have been three complaints recorded since the last inspection, all from residents that have been satisfactorily dealt with. The care manager continues to address the issue of complaints at staff meetings 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 four residents were checked and found to be accurate. Church View DS0000003120.V297940.R01.S.doc Version 5.2 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 the following standard(s): 24, & 30. Quality in this outcome area is adequate, and this judgement has been made using the evidence available and a visit to the home. This outcome area has been affected by the fact that there are a number of premises related issues affecting residents that need attention. EVIDENCE: The home is split into 3 separate units, in separate buildings, and the premises appear safe apart from the danger posed by some residents continuing to smoke in their bedrooms. The premises are close to shops and local transport. Each house has its own lounge/dining room and separate kitchen facilities, and any private consultations are usually carried out in the residents own bedroom, or the office. Since the last inspection, the home has registered an additional bedroom, in the Vicarage unit and this is now occupied. In addition, there have been further developments in both Canterbury and York houses to install separate laundry areas. Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 20 It was disappointing to note that the general deterioration in the current standard of the décor and some fixtures and fittings, identified in the previous two inspection reports have still not been dealt with as follows: 1. The seals in many double - glazed units in the have “blown” making it difficult to see out of some windows. 2. The stair and landing carpet in York house is filthy and the upstairs needs redecorating. 3. The kitchen floor surface in Canterbury House is pitted with cigarette burns as is the lounge carpet in Canterbury lounge. The inspector learned that it is now practice that any deliberate/wilful damage by residents to the fabric, fixtures and fittings of the premises, is discussed with the residents and their CPN’s/social workers and an agreed recompense is arranged and recorded. There is a policy and procedure on infection control, and the home was found to be free from odours on this inspection, for the benefit of residents and staff. Church View DS0000003120.V297940.R01.S.doc Version 5.2 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 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 34, 35, & 36. Quality in this outcome area is good, and this judgement has been made using the evidence available and a visit to the home. Staff NVQ attainment, and other training is very good that can only be to the benefit of residents. EVIDENCE: The care manager continues to arrange updated in-house training for staff, on the different forms of mental heath, and its effects and how it can present in different residents, and a training session has been arranged for the day after the inspection. Staff have the opportunity to ask about any aspect of their practice at any time and in supervision sessions that are up to date. The home currently has a staff achievement level of just over 90 at NVQ Level 2, with five members of staff having achieved NVQ level 3 a factor that together with other training enables them to meet the assessed needs of residents. 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. Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 22 There were 23 residents accommodated at this inspection, and there are 22 care staff employed on a permanent contract split between the care manager, deputy care manager, seniors in charge of a shift, and other care staff. In addition the home employs 3 domestic persons, two part time activity coordinators, and has a vacancy for a maintenance person. Since the last inspection the deputy care manager has been permanently appointed to the same post at Westfield House to support the care manager there. A senior carer at Church View has now been appointed deputy care manager at the home to fill the vacancy. There is a recruitment policy and procedure, and the file of one new member of staff employed since the last inspection in December 2005 was checked, and found to be satisfactorily recorded. One member of staff has been dismissed since the last inspection, because of her poor attitude to her work including her attitude towards residents. 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. Formal supervision and appraisal of care staff is being carried out to the benefit of residents. Church View DS0000003120.V297940.R01.S.doc Version 5.2 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 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 39, & 42. Quality in this outcome area is good, and this judgement has been made using the evidence available and a visit to the home. The conduct and management of the home generally promotes the health and safety interests of residents and staff. Church View DS0000003120.V297940.R01.S.doc Version 5.2 Page 24 EVIDENCE: The care manager has a background in working in residential care, and was 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. Since the last inspection, the care manager has successfully completed the CSCI “ Fit Person” interview. The care manager continues to undertake periodic training and since the last inspection has undertaken training in Health and Safety, Crisis Intervention Training, and Budgetary Control. Resident and relatives questionnaires are used as part of the company’s quality assurance system, which are returned to Craegmoor management for analysis, and then eventually sent to the home where the original comments are available for any potential resident/representative to look at. Other methods of obtaining residents views are via staff meetings, or by general interaction with residents on an informal basis. Six residents completed the CSCI “Have your Say About” document given to them on this inspection. 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, and examples include, the moving and handling of shopping, and any other item of equipment or furniture constituting a potential safety hazard. The fire safety records were in order, and 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 on the 5th August 2005 by a corgi registered person,and the electrical check of the hard wiring had been carried out on the 12th May 2006. The PAT testing was carried out on the 28th September 2005, and the Legionella test is due. 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. 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. Church View DS0000003120.V297940.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 Adults 18-65 have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 x 2 3 3 3 4 x 5 x INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score CONCERNS AND COMPLAINTS Standard No Score 22 3 23 3 ENVIRONMENT Standard No Score 24 2 25 x 26 x 27 x 28 x 29 x 30 3 STAFFING Standard No Score 31 x 32 3 33 3 34 4 35 3 36 3 CONDUCT AND MANAGEMENT OF THE HOME Standard No 37 38 39 40 41 42 43 Score 3 3 x 2 x LIFESTYLES Standard No Score 11 x 12 3 13 3 14 3 15 3 16 3 17 3 PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Score 3 3 3 3 3 x 3 x x 3 x Church View DS0000003120.V297940.R01.S.doc Version 5.2 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. Standard YA9 Regulation 12 Requirement The registered person must ensure the health safety and welfare of all residents and staff with reference to those residents still smoking in their bedrooms, and other non-designated areas. The registered person must ensure that the homes premises are suitable for its stated purpose. Timescale for action 15/07/06 2. YA24 23 15/08/06 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 DS0000003120.V297940.R01.S.doc Version 5.2 Page 27 Commission for Social Care Inspection Doncaster Area Office 1st Floor, Barclay Court Heavens Walk Doncaster Carr 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 DS0000003120.V297940.R01.S.doc Version 5.2 Page 28 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. Re-publishing this information is in breach of the terms of use of that website. Discrete codes and changes have been inserted throughout the textual data shown on the site that will provide incontrovertable proof of copying in the event this information is re-published on other websites. 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