Inspection on 09/06/05 for Church View

This inspection was carried out on 9th June 2005.

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

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

Other inspections for this house

Church View 02/12/09

Church View 25/09/07

Church View 17/07/06

Church View 24/10/05

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 L13 7EB Lead Inspector John McCabe Unannounced 9 June 2005 09.30 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for 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 F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 3 SERVICE INFORMATION Name of service Church View Address Green Lane Liverpool L13 7EB Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 0151 228 0997 Ashbourne (Eton) Ltd Karen Witterick Care Home with Nursing 50 Category(ies) of Old Age 50 registration, with number of places Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: 1. 44 Nursing OP and 44 Personal Care OP within the overall number of 50 2. 6 DE(E) Personal Care within the overall number of 50 3. Two named service users under 65 year of age may be accommodated within the overall number of 44 Personal Care OP 4. One personal care bed OP registered to accommodate one named service user with DE(E) 5. One named service user under 65 years of age may be accommodated within the overall number of 44 Nursing OP 6. One named service user under 65 years of age may be accommodated 7. One (1) named female service user under 65 years of age (DE) to be accommodated in the 6 DE/E unit. Date of last inspection 1 November 2004 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 service users who require personal care. All parts of the home are accessible to service users, including the garden areas and upper floors via a lift. Communal lounges and dining rooms are furnished and decorated in a domestic homely way. Service users may take their meals in the dining rooms or in the privacy of their own room. Visitors are encouraged to visits at any reasonable time of day. All service users can access their NHS entitlements. Therapeutic diets can be catered for in the home, if service users have any medical conditions. Ashbourne Healthcare Ltd, have responsibility for the home since February 2004. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection was undertaken on the 9th June 2005, commencing at 10:00 hours. 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? What they could do better: Ashbournes pre admission nursing assessment documentation is comprehensive, and allows the person carrying out the assessment to gain important and useful information about the resident before they are admitted to the home. However there were examples were this assessment was not fully complete and possible relevant care information was not gained about the prospective resident. Presently, the six residents on the dementia unit, cannot access the garden space without being escorted by a carer. This lack of freedom for the resident restricts their choice and preferences. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 6 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 F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4,5,6. The Homes Statements Purpose is up to date and gives prospective residents and their families enough information about the home to allow them to make an informed choice as whether the home will be able to meet their needs. The format for the resident’s preadmission nursing/personal care assessment documentation is thorough. However, it is not always completed as necessary. This means that the care needs of the residents are not always identified before being admitted to the care home. 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 to allow them to gain an insight into the home and whether the home will be right for them.. The name of the home manger should be included in the homes Statement of Purpose. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 9 The homes senior nurses are expected to undertake a pre admission nursing assessment on residents before they are admitted to the home, to ensure care needs can be met. However there were several examples of incomplete documentation. As this completed document is the basis of the residents care plan when admitted to the home, it is important that all relevant information is gained before admission to the home and recorded appropriately. There were also a number of instances when clinical abbreviations were recorded. These should be avoided however if they are to be used it is crucial that all staff caring for the residents understand what has been written particularly if English is not their first language. 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 met. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 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 standard(s) 7,8,9,10. Resident’s individual health, personal and social care needs are not clearly recorded, and records do not provide care staff with the information they need to meet the residents care needs. However 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, and is 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 residents with reported pressure sores. Most of the care staff have undertaken training on tissue viability and this is seen as good practice. The Primary Care Trust (PCT) tissue viability nurse will also visit the home at any time if needs arise. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 11 All residents in the care can access their NHS entitlement that includes access to GPS, dentist, chiropodists, and opticians. It was of concern to note that in one resident’s personal file, a senior nurse had written “Not for Resus” (Resuscitation), this means that the resident would not have any clinical interventions at the time of dying (This information was copied from hospital notes). The inspector requested the senior nurse to provide documented evidence from the either the resident’s family, GP, Consultant, or social worker on how and when this decision was made. No evidence to this effect could be offered. It is strongly advised that the management of the home seek guidance as to the appropriateness of such recordings within the Care Home environment. This should extend to having a clear policy that states the organisations position in this regard. The inspector told the senior nurse to immediately ensure that details copied from hospital notes are valid for the resident and family. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 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 standard(s) 12,13,14,15. Residents do have some choice and flexibility about how they choose to spend their day in the home, and they can pursue leisure activities according to their choice and preferences. This encourages residents to maintain their independence and individuality. EVIDENCE: Residents in the home are asked on admission, about their lifestyle, choice of foods, and choices and preferences of the social activities they would like to participate in. 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 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 according to their choices and preferences. Residents engage in bingo, sing a longs and a guest entertainer visits the home on a regular basis. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 13 The homes owners are organising a meeting for all the activity coordinators (Ashbourne homes) in the Merseyside area, to further improve the service for all residents. 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. The main meal of the day is served early evening, as requested by the residents. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 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 standard(s) 16,17,18. The home has a satisfactory complaints system in place and there is 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 safeguarded from any potential 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 recent General Election. 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 also evidence that many of the staff in the home had undertaken training on POVA protocols as well as the companies Whistle Blowing Policy. These measures assist in safeguarding residents from possible abuse. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 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 standard(s) 19,20,21,22,23,24,25,26. Overall the standard of decor within this home is good, with evidence of continuing improvements, through maintenance and planning. The home does present as a homely, safe and comfortable environment for the residents although there are some areas that require attention. EVIDENCE: The care home environment is good; all areas of the home are clean, light, well decorated and maintained including the rear garden area. On the day of the inspection vacant bedrooms were being painted and decorated. The gardens of the home are well maintained and tended, and offer peaceful pleasant surroundings for the residents. All the corridors in the home have been re painted, which makes them brighter and more cheerful. Many of the residents have personalised their own bedrooms with photographs and memorabilia that gives a more homely feel to their room. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 16 Residents in the dementia unit currently have no secure garden area. They at present cannot access the garden without being escorted by care staff. 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. Consequently it is recommended that the management of the home should consider providing secure garden space for the residents. The homes updated infection control policy includes the prevention and spread of Methicillin Resistant Staphylococcus Aureus and Hepatitis B that minimise the potential risks to residents. Communal bathrooms and communal toilets in the home, need to be upgraded, especially in respect of the floor covering and the re grouting of tiles. The carpet in the resident’s main lounge also needs to be replaced, as it is worn and stained Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29,30. The standard of vetting and recruitment practices needs to be more robust with the appropriate checks being carried out on all new staff particularly agency staff. Current practices cannot ensure that the residents are not unnecessarily 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 needs to be developed to ensure it is in accordance with the National Minimum Standards. On the day of the inspection staff files were reviewed and it was evident that an agency nurse recently employed by the home had two work references that were supplied by her friends and colleagues working in another care home. It would be safer practice to take up one reference with the prospective employees manger, not friends. All permanent staff in the home have up to date CRB/POVA enhanced certificates, so ensuring the safety of the residents. The Personal Identification Numbers (PINS) of all the registered nurses in the home, where present and documented on Nursing Midwifery Council (NMC) stationary. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 18 Mandatory and specialist trainings for all staff is ongoing in the home and upon completion this is noted on each persons file. This assists in ensuring that the assessed and changing needs of the residents are met. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,34,35,3,6,37,38. Staff morale is high in the care home, resulting in an enthusiastic workforce who work positively with residents to improve their whole quality of life. The home regularly reviews aspects of its performances through a good programme of self-review and consultations, which include seeking the views of residents, staff and relatives. EVIDENCE: An experienced first level nurse with 17 years of direct care and home management experience, manages the home; currently the manger has also completed a NVQ Level 4 care programme. Staff and residents told the inspector that, the home was run in an open and transparent way. Both staff and residents reported that there are regular Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 20 meetings with the manager; the meetings are minuted and action identified is taken. All staff in the home have documented supervision six times per year, this ensures that all staffs have the opportunity to discuss with the manager, and 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 finical affairs, 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. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 2 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 2 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 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score 3 3 3 3 3 3 3 3 3 3 3 Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 22 yes Are there any outstanding requirements from the last inspection? Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 23 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 4 Regulation 14 Requirement The registered person must ensure that all service users care documents, including, pre admission assessment, admission notes and daily health records, are accurate and reflect the service users care needs. Previous timescale of the 30th November 2004 not met. The registered person must ensure that when records are made in residents care plans reflecting their wishes at times when they are very ill that there is a clear basis supported by evidence for the decision reached. This refers to the statement of Not for resucitation The registered person must ensure that the communal bathrooms, toilets are upgraded, specifically they must be repainted, upgrade floor covering and tiles must be re-grouted. The registered person must ensure the care homes recruitment policies are robust, and that there is evidence that at least one reference is taken from the staff members previous employer. Timescale for action 30th June 2005 2. 7 12 Immediate 3. 26 23 31st July 2005 4. 29 19 Immediate Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 24 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. Refer to Standard 19 11 Good Practice Recommendations It is recomended that the Corporate Management of the home provide a secure garden space for those residents with dementia. It is strongly recommended that the management of the home seek guidance as to the appropriateness of recordings concerning residents wishes should they become very ill within the Care Home environment. This should extend to having a clear policy that states the organisations position in this regard. Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 25 Commission for Social Care Inspection Liverpool Office 3rd Floor, 10 Duke Street Liverpool L1 5AS National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI Church View F52 F02 S59877 Church View V232265 090605 Stage 4.doc Version 1.30 Page 26 - Please note that this information is included on www.bestcarehome.co.uk under license from the regulator. 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