Inspection on 18/10/06 for Church View Nursing Home

This inspection was carried out on 18th October 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 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 Nursing Home 31/01/08

Church View Nursing Home 04/01/06

Church View Nursing Home 15/09/05

Church View Nursing Home 01/11/04

Church View Nursing Home 04/08/04

Similar services:

The Highlands

Turret Villa Retirement Home

Moor House

Blenheim House

1 Lanark Close

Mendip House

Beaconsfield Court Care Home

Ann Charlton Lodge

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

CARE HOMES FOR OLDER PEOPLE Church View Nursing Home Thompson Street Norton Stockton-on-Tees TS18 2NY Lead Inspector Katherine Acheson Key Unannounced Inspection 18th October 2006 10:00 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 Nursing Home DS0000000160.V316296.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 Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church View Nursing Home Address Thompson Street Norton Stockton-on-Tees TS18 2NY 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) 01642 802490 01642 802491 Teesside Health Care Limited Mrs Denise Mary McPhee Care Home 47 Category(ies) of Old age, not falling within any other category registration, with number (0), Physical disability over 65 years of age (0) of places Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 23 service users who require nursing care can be admitted to the home from age 55 . This variation to age is for one named individual, until such a time as the placement is no longer required. 4th January 2006 Date of last inspection Brief Description of the Service: Church View Nursing Home is registered to provide personal and nursing care to forty-seven older people. The home is situated on Thompson Street in Stockton, and is close to the town centre and other local amenities. The home is a modern, two storey, purpose built facility, which is divided into two units. The ground floor of the home accommodates a maximum number of twenty-three residents who require nursing care, and the first floor of the home accommodates a maximum number of twenty-four residents who require personal care. Each unit has a lounge, dining area and lounge designated for those residents who wish to smoke. All bedrooms are single in nature and provide ensuite facilities, which comprises of a toilet and hand washbasin. All bedrooms meet spacial requirements of National Minimum Standards. There is a car park to the front of the home and a pleasant enclosed garden/patio area to the rear, for resident use. The cost of care at the time of the inspection visit (depending on the category of care) ranged from £337 to £472 per week. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced key inspection lasted for six and a half hours. Four residents, one relative, one care assistant, the office administrator and the laundry assistant were spoken to during the inspection. A lengthy discussion also took place with the Manager. Numerous records including care plans, menus, quality assurance, complaints and staff recruitment and training records were examined. A tour of the premises was carried out. Requirements identified at the last inspection in January 2006 were re-visited. The details of any issues identified at this inspection requiring action are to be found at the back of this report. What the service does well: What has improved since the last inspection? All requirements identified at the last inspection have been addressed. Since last inspection a number of areas of the home have benefited from redecoration and replacement carpets. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 6 The Manager and staff at the home have worked extremely hard to improve the standard of care planning of residents. Care plans examined were detailed and specific to the individual. 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. The summary of this inspection report can be made available in other formats on request. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 3, 6 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Assessments of prospective residents are carried out to ensure that the home can meet their needs. EVIDENCE: Prospective residents receive an assessment that is carried out by a social worker or other health care professional to ensure that the home can meet their needs. Staff at the home then carry out their own pre-admission assessment to ensure that the needs of the resident can be met at Church View Nursing Home. Records were evidenced on residents files examined during the inspection to confirm that this is the case. The home does not provide intermediate care. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 9 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): 7, 8, 9, 10 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home provides a good standard of care. Care plans are detailed and specific to the individual, which will help to ensure that resident’s needs are met. Residents are mainly treated with respect and their right to privacy is upheld. In general good procedures are in place to ensure safe practice in respect of the handling of medication, however improvement is needed in respect of record keeping and ensuring that staff follow correct sequence when administering medication from blister packs. EVIDENCE: Three plans of care were examined during this inspection. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 10 Care plans examined were detailed and included specific care and intervention required to assist the resident. Care plans showed clear evidence of choice and preferences in respect of the way the care was to be delivered. Care plans are effectively evaluated on a monthly basis. Evaluations included a baseline of the resident’s capabilities, deteriorations and improvements made. Risk assessments were evident on resident files examined during the visit and included intervention required to minimise the highlighted risk. Risk assessments were also evaluated to confirm effectiveness. Records were examined to confirm that the Manager carries out an audit of the accident record on a regular basis, however this audit appears to be more statistical rather than trying to identify if there is a pattern or common factor to accidents/incidents/falls. A discussion took place with Manager in respect of this. Four residents and one relative were spoken to at length during the visit. In general residents spoke positively about the care that they received, however they did say that some care staff were better than others. One resident said, “It’s quite nice, the staff are good, I have no complaints”, another said, “It’s quite nice here, you can please yourself. I have made friends; the lady round the corner is very nice. Some staff are quite nice, some are alright”. One resident spoken to said, “The majority of staff are ok, however some can be a bit sharp”. Another resident said, “It is a good home, everybody looks after you well. They are pretty prompt at answering the buzzers” Residents spoken to confirmed that their dignity and privacy was respected. The home has a medication policy. Nurses administer medication to residents on the nursing unit and Senior Care Assistants administer medication to those residents on the residential unit. The Manager said that those Senior Care Staff responsible for the administration of medication to residents on the residential unit have undertaken medication training and have had their competency checked. During the inspection arrangements for receiving, storing, administering, recording and disposing of resident’s medication on the nursing unit were observed and examined. Records were available to confirm that the home keep a record of all medication coming into the home. Medication was stored securely. The home has a system in place for the returning of unused medication for destruction by a licensed company, however, an accurate record of medication returned is not kept. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 11 The home has a separate dedicated fridge for the storage of medicines that require cool storage. The fridge temperature is taken and recorded on a regular basis, however records examined confirmed that on occasions the fridge temperature was too warm. This was pointed out to the Manager at the time of the inspection who said that she would take immediate action to address the problem. During the visit an audit trail of a residents medication was undertaken. This resident was prescribed one or two tablets when required for pain. Staff were recording when medication was given but not how many tablets. The homes medication is dispensed in blister packs, however an audit trail of medication showed that staff were not always following the sequence of the blister packs, as they should do. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate and enjoyable activities take place at the home providing residents with stimulation. Residents are able to exercise choice and control. Visitors are encouraged and made to feel welcome at anytime. Food provided is varied, appetizing and appealing and provides residents with a wholesome balanced diet EVIDENCE: The home employs and Activity Co-ordinator to provide and arrange a plan of activities, entertainment and outings for residents. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 13 The Activity Co-ordinator works twenty-five hours per week from Monday to Friday. The Manager said that activities undertaken on a weekly basis include bingo, dominoes, a video night on a Thursday evening and beauty which consists of nail care and hairdressing. Residents have been on recent trips out to Seaton Carew and Middlesbrough Little Theatre with another theatre trip planned to go and see “Roll out the Barrel” at the Town Hall Theatre in Hartlepool. One resident spoken to during the inspection said, “ There is plenty going on, I join in yahtzee, bingo and we have a film night on a Thursday. Last week we watched The King and I and we all had our supper together it was quite nice”. One resident spoken to said that they chose not to join in the activities saying, “I am a private individual”. One resident said that they would like to go to the pub on lunchtime. This was pointed out to the Manager at the time of the visit who said that she would try and arrange this. The home supports residents to practice their religion and that visits from clergy are available to the home, residents spoken to confirmed that this was the case. Residents interviewed spoke of flexibility in routine and freedom of choice. Residents spoken to during the inspection said that contact with family and friends is encouraged and that visitors are made to feel welcome at any time. A relative spoken to during the visit said, “I am always made to feel welcome and I always get a cup of tea or coffee”. The home has a four-week menu plan with a choice available at each mealtime. Mealtime was observed. Residents were seen to be enjoying the food provided. On the day of the visit roast beef, yorkshire puddings with vegetables was on the menu, however some residents had opted for an alternative. One resident was heard saying that he was enjoying his omelette. One resident said, “The food is good, I enjoyed my dinner today”, another said, “The food is spot on there is always choice”. One resident said, “The cook is experimental she has made some beautiful home made broths. The roast beef today was very tasty and if we have lamb it is very good”. One resident said that although the food is excellent they would like applesauce to be served when they have pork and stuffing to be provided when they have chicken. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 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. JUDGEMENT – we looked at outcomes for the following standard(s): 16, 18 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Appropriate systems are in place in respect of making a complaint. Residents and relatives are supported to make any complaint that they feel necessary. Residents residing at the home said that they felt safe. Adult protection procedures are in place, however lack of staff training leaves residents vulnerable. EVIDENCE: The home has a complaints policy/procedure in place, which includes residents/relatives of their right to complain to any commissioning authorities such as the Primary Care Trust or Social Services. The Manager said that there has been three complaints in the last twelve months. Residents spoken to during the inspection said that they would feel comfortable in raising and concern or making a complaint to the staff or management of the home. One resident said, “The Manager is very approachable”. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 15 The Manager said that adult protection training has taken place at the home, however acknowledged that not all staff had attended and that training had not been provided on a regular basis. The Manager said that she has now rectified this and organised with a training company a rolling programme of adult protection training, which is to commence in the next few weeks. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 16 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): 19, 20, 26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The standard of the environment within this home is good providing the people who live there with and attractive, homely and comfortable place to live Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 17 EVIDENCE: The Manager accompanied the Inspector on a tour of the home. The home is well maintained with appropriate and comfortable furnishings provided. Since the last inspection the lounges designated for those residents who wish to smoke have benefited from re-decoration, new carpets and new furniture. The ground floor corridor of the home has been re-decorated and at the time of the inspection visit the first floor corridor was in the process of redecoration. Communal areas are pleasantly decorated and homely. Numerous new chairs and recliners had been provided. Bedrooms visited during the inspection were personalized, some of which had benefited from re-decoration and new carpets. The home has a policy in respect of control of infection. Staff spoken to during the inspection said that there was always a plentiful supply of protective clothing. Appropriate laundry facilities were in place. One resident said, “The laundry service is excellent”. On the day of the inspection the home was observed to be clean and odour free. One resident said, “The home is always clean and there never is an odour” Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 18 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): Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Robust recruitment procedures are followed which helps to protect residents. Staffing levels are appropriate Staff receive induction training and a rolling programme of mandatory training is provided for staff EVIDENCE: Staffing rotas examined during the inspection confirmed that on the twentyfour bedded residential unit there is one senior care staff member and two care assistants on duty between the hours of 08:00 and 21:00. On night duty there is one senior carer and one care assistant. On the twenty-three bedded nursing unit there is one trained nurse on duty twenty-four hours a day. In addition there are four care assistants on a morning, three on an afternoon, four on an evening and two care assistants on night duty. The Manager of the home works five days supernumerary a week. 69 of care staff working at the home have achieved an NVQ level 2 in care. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 19 Three staff files were examined at random during the inspection. Records examined contained two references, proof of identity and appropriate Criminal Record Bureau checks that had been received prior to the commencement of employment. The homes reference request has been updated to seek confirmation of dates of employment from the previous employer. Records were examined to confirm that all newly appointed staff complete induction training. Records were available to confirm that moving and handling, fire training and other training relevant to the job that staff do is undertaken on a regular basis. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 20 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): 31, 33, 35, 38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The home is well managed, residents health, safety and well being is promoted. The home seeks the views of residents to ensure that it is managed with their best interest. Systems are in place to ensure resident’s money is managed appropriately. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 21 EVIDENCE: The Manager, Denise McPhee is a first level Registered Nurse who has worked in the nursing and social care environment for many years. The Manager has achieved her NVQ level 4 in Management. A resident spoken to during the inspection said, “This is a very well run place. The Manager is very good she will come and have a chat to you about this and that. The number two (Deputy Manager) is also excellent”. Quality assurance and quality monitoring practices are in place. Surveys are sent out to residents on an annual basis to see if they are happy with the home and care that is provided. The results of the survey are published and made available to residents and relatives. It was highlighted at the last inspection that copies of reports from monthly visits carried out by Directors of the home were not forwarded to the Commission for Social Care Inspection, this has now been addressed. The home operates an effective system in which they look after the personal allowance of a number of residents. The home operates a rolling programme of servicing appliances and equipment. Records examined at random confirmed that the home’s fire extinguishers, fire alarm system, electrical hard wiring and gas boilers are serviced on a regular basis. The Windows on the first floor of the home environment are restricted to ensure safety for the people living there. Records were available to confirm that tests of the fire alarm system are carried out. Water temperatures in resident bedrooms and communal bathrooms are taken on a regular basis by the home’s handyman. Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 22 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 X X 3 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 3 9 2 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 2 3 3 X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 X 3 X 3 X X 3 Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 23 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. 1 Standard OP7 Regulation Requirement Timescale for action 30/11/06 2 OP9 3 OP18 13, 14, 15 The homes accident audit must be developed further to identify residents at risk or any patterns to falls. Following the audit a resident risk assessment must be developed/updated 18/10/06 13 • The Registered Person must ensure that an accurate record of medication to be returned to the licensing company for destruction is kept • The Registered Person must ensure that staff who administer medication follow the correct sequence when administering medication from blister packs • The Registered person must ensure that medication requiring cool storage is kept at the correct temperature • The Registered Person must ensure that staff record the dosage of medication administered 13 All staff must receive adult 30/11/06 DS0000000160.V316296.R01.S.doc Version 5.2 Church View Nursing Home Page 24 protection training on a regular basis 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 Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 25 Commission for Social Care Inspection Tees Valley Area Office Advance St. Marks Court Teesdale Stockton-on-Tees TS17 6QX 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. Extracts may not be used or reproduced without the express permission of CSCI Church View Nursing Home DS0000000160.V316296.R01.S.doc Version 5.2 Page 26 - 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. 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