Inspection on 30/01/06 for Church View Nursing Home

This inspection was carried out on 30th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Adequate. 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 Nursing Home 29/09/09

Church View Nursing Home 15/04/09

Church View Nursing Home 01/04/09

Church View Nursing Home 15/10/08

Church View Nursing Home 15/08/07

Church View Nursing Home 14/06/06

Church View Nursing Home 01/11/05

Church View Nursing Home 09/02/05

Church View Nursing Home 06/04/04

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 Church View Nursing Home Rainer Close Stratton St Margaret Swindon Wiltshire SN3 4YA Lead Inspector Steve Cousins Unannounced Inspection 30th January 2006 09:30 X10015.doc Version 1.40 Page 1 The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 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 DS0000052415.V275076.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Church View Nursing Home Address Church View Nursing Home Rainer Close Stratton St Margaret Swindon Wiltshire SN3 4YA 01793 820761 01793 820180 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) Hallmark Healthcare (Swindon) Ltd Vacant Care Home 43 Category(ies) of Old age, not falling within any other category registration, with number (43), Physical disability (3), Terminally ill (3), of places Terminally ill over 65 years of age (3) Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. No more than 3 service users with a terminal illness may be accommodated at any one time The staffing levels set out in the Notice of Decision dated 1 December 2003 must be met at all times 1st November 2005 Date of last inspection Brief Description of the Service: Church View is a purpose built care home providing nursing care and accommodation for up to forty-three residents. The home is part of the Hallmark Healthcare Group. The registered manager post is currently vacant. The home is located within a residential development in Stratton St Margaret, situated on the outskirts of Swindon, and is within walking distance of a local shop. Accommodation comprises of 29 single rooms and 7 double rooms, located over two floors with all having en suite facilities. Residents also have access to a lounge and dining area on each floor and a ground floor conservatory, which leads out to an enclosed garden, and patio area. As the home provides nursing care, registered nurses are on duty at all times, supported by care assistants, domestic, laundry, catering, maintenance and administration staff. Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place between 9.30 am and 4.00 pm on the 30th January 2006. The findings from this inspection are based on a tour of the premises, speaking to residents and the staff, and inspecting a number of records. The inspector then met with Mrs Beresford to report the findings of the inspection. An additional inspection in response to a complaint had been held on the 19th December 2005, prior to this inspection, the findings of which are contained in this report. What the service does well: What has improved since the last inspection? What they could do better: There is a need to ensure frail residents who have problems eating are given nutritional supplements. Care plans need to be completed as soon as possible after a resident is admitted to ensure that the care given meets their needs. Any plans or assessments need to be signed and dated by the person completing them. Complaints need to be recorded more thoroughly and action taken in response to abuse allegations needs to be more robust. The owners, Hallmark Healthcare, need to undertake monthly visits more regularly in order to ascertain residents’ views on the home. The kitchen requires some further cleaning and refurbishment Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 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 Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 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 DS0000052415.V275076.R01.S.doc Version 5.1 Page 8 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2 and 5. Standard 6 does not apply to this home. Prospective residents and their advocates have the information and opportunity to make an informed choice about the home. Residents or their advocates are issued with contracts detailing terms and conditions of occupancy. EVIDENCE: A brochure and service users guide is available to prospective residents and visits to view the home are encouraged, although it was stated that it was normally relatives who undertook these visits. A copy of the most recently available CSCI report was also available. One resident confirmed that they had visited the home prior to moving in. Terms and conditions of residence for residents who purchase their care privately and for those who are funded by local authorities are issued and include details of fee arrangements. Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 7 and 8 Residents’ health care needs appear to be met however not all had their needs assessed or set out in a care plan. There is a need to ensure that, where appropriate, nutrition supplements are given to frail residents. EVIDENCE: The standard of care planning had improved since the previous inspection however there is still a need to ensure that plans are in place promptly following admission. A resident admitted on three weeks prior to the inspection had only minimal information and some assessments were incomplete. Another admitted five days prior to the inspection did not have a plan in place to direct care. Care also needs to be taken to ensure that all documentation is signed and dated by the person completing it. One of the findings of the additional inspection held on 19th December 2005 was that some frail residents were not receiving adequate fluids. There had been an improvement noted at this inspection. Staff were observed giving frail residents drinks and record charts indicated that adequate fluids were provided. Another finding was that residents who were in the lounge areas were not receiving adequate pressure relief. During this inspection it was noted that residents in lounges were sat on pressure relief cushions and that staff Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 10 attended to residents promptly. Frail residents who were in bed were receiving appropriate care and had pressure relief mattresses. Following observation over residents lunchtime and a review of intervention charts, there was little evidence to suggest that nutritional supplements are given to those residents whose appetite is poor, or who found it difficult to eat. This was discussed with Mrs Beresford. Records indicated that GP’s attended the home, as did other health care professionals. Two residents confirmed that staff had arranged for them to see their GP’s recently. Standard 10 was not fully assessed however the additional inspection was in response to a complaint that raised some concerns that residents were not always being treated with respect. Mrs Beresford was aware of this and stated that the issue had been discussed at a staff meeting in order to raise staff awareness. Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 11 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12 and 13. There is a commitment to meet the residents’ social, recreational and religious needs and residents are able to maintain contact with family, friends and the community. EVIDENCE: An activity person is employed and a bingo session was held in the afternoon of the inspection. Activity records were available indicating a range of in house and external events. Religious services are also arranged. Residents spoken with indicated that they were happy with the activities provided; one did not attend any but stated that this was their choice. Many residents spent time in the home’s sitting rooms and some preferred to remain in their rooms watching TV or listening to the radio. Appropriate social interaction was noted between staff and residents. It was stated that there are no restrictions on visiting unless at the residents request. Visitors were in the home during the inspection and some residents confirmed that they had contact with friends and relatives. Visitors could be received in residents’ rooms or in the communal areas. Residents’ comments indicated that links with the local community were mainly via external activities or trips out with relatives. Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 12 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18 Systems are in place to ensure that complaints are dealt with however some improvement is required regarding how they are recorded. As far as possible, residents are protected from abuse, however allegations need to be dealt with more rigorously, using the correct procedures. EVIDENCE: A complaints procedure is available. A resident stated that they had approached the manager recently with a concern and that this had been dealt with to their satisfaction, however this issue had not been recorded in the complaint log. A recent complaint received from a relative had been recorded and investigated promptly by Mrs Beresford. CSCI received a complaint about the care of residents in the home, which related to the provision of adequate drinks and food, residents comfort, personal hygiene, personal choice and staffing levels. An additional inspection was held on the 19th December 2005 that found that three elements of the complaint were upheld, three were not upheld and one unresolved. An adult protection procedure was in place along with a whistle blowing policy. Copies of the local ‘No Secrets in Swindon and Wiltshire’ document, which details action to be taken in the case of suspected abuse, were available in each resident’s room. As recommended at previous inspections, the adult protection procedure and whistle blowing policy should include reference to the local ‘No Secrets in Swindon and Wiltshire’ document. Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 13 A social services review form indicated that a resident had concerns regarding the attitude of some staff members, which may be construed as abuse. This was brought to the attention of the manager who was aware of the issue, but had yet to contact the relevant member of the social services adult care team or the resident to further discuss this issue and ascertain if further action was required. Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 14 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 20,21,22,24 and 26 The home is generally clean and comfortable and suitable for the needs of the residents. There are adequate bathing and toilet facilities. Specialist equipment is available where required, but more adjustable beds are needed to avoid manual handling risks to staff. Improvements are required to the fabric of the kitchen to ensure hygiene standards can be more easily maintained. EVIDENCE: The accommodation is sited on two floors, the upper being accessed by a passenger lift and stairwell. The home has spacious communal and dining areas on both floors. Furnishing in communal areas is domestic in character and in good condition. There are adequate and suitable toilet and bathing facilities. All bedrooms have en-suite facilities and in addition, there are two bathrooms and separate toilets on each floor. Separate sluicing facilities are also provided on each floor. The home was purpose built as a nursing home. The corridors and rooms are accessible and mobility equipment and aids available. Toilets and bathrooms Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 15 contain grab rails and manual-handling equipment is available. A call bell system is installed and was working at the time of the inspection. Residents’ rooms were heated and carpeted and the furniture and decoration was of a satisfactory standard. There are signs of individualisation in some rooms. Not all residents’ who are in receipt of nursing care have adjustable height beds presenting a manual handling risk to staff. More had been purchased since the last inspection and Mrs Beresford stated that further beds were on order. The home was generally clean and tidy and there were no unpleasant odours. Disposable gloves and aprons are available throughout. There were two cleaners working on the day of the inspection. The laundry was clean and tidy and infection control measures were in place. There had been an improvement in the cleanliness of the kitchen floor following the purchase of appropriate cleaning equipment, however not all areas under benches and equipment had been fully cleaned. Work needs to be undertaken to the area around the sink to clean and cover exposed pipe work and some wall tiles are in poor condition. Two fridges require replacement and the manager stated that these had been ordered. Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 16 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27 and 29 Residents needs appear to be met by the numbers and skill mix of staff and the homes recruitment practice protects them. EVIDENCE: It was indicated during the additional inspection in December, that there were not always enough care staff members on duty to meet residents’ needs. It was felt that this was a particular problem in the mornings. A review of staffing levels had occurred along with some changes in the way that work is allocated. Residents and staff comments, allied to the inspector’s observations, indicated that staff were now able meet residents needs during this period. There were no overlong delays in responding to call bells and residents did not have to wait to long to get up. Duty rotas indicated that the homes minimum staffing notice was adhered to, which was an improvement on the previous inspection held in November 2005. The records of staff recruited since the previous inspection were reviewed and included all the required documentation. Staff had not commenced work prior to a POVA check being obtained and all had undergone a CRB check. Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 17 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 33. There are systems in place to ensure residents’ views are sought; however these need to be enhanced by regular visits by the provider. A registered manager is yet to be appointed. EVIDENCE: The home does not currently have a manager who has been registered with the Commission but recruitment is currently being addressed. Maureen Beresford, a registered nurse is currently Acting Manager. A full time administrator is employed to support her. Records indicated that residents and relatives meetings were held. Monthly unannounced visits by a representative of the registered provider, Hallmark Healthcare, have not been undertaken since June 2005. This was a requirement of the previous inspection held on 1st November 2005. These visits are a legal requirement and are an opportunity for providers to ensure Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 18 the home is being run in the residents’ best interests. Reports of visits need to be forwarded to the local CSCI office. Standard 38 was not fully inspected however fire safety records indicated that practice was safe. A tour of the building indicated that there were no hazards or risks to safety evident. Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 3 X X 3 X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 X 15 X COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 2 X 3 3 3 X 2 X 2 STAFFING Standard No Score 27 3 28 X 29 3 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X 2 X X X X X Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? Yes 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 15 (1) Requirement The registered person is required to ensure that care plans are in place as soon as is reasonably practicable following admission. The registered person is required to ensure that residents’ nutritional needs are met. The registered manager is required to ensure that a record is kept of all complaints made that include details of any investigation and action taken. The registered person shall ensure that all allegations of abuse are followed up promptly, following local guidelines, and any action taken recorded. The registered provider is required to ensure that manoeuvrable, adjustable height beds are available for all residents currently in receipt of nursing care. Requirement from the previous inspection held 1st November 2005, met in part. The registered provider is required to ensure that all areas of the kitchen floor be DS0000052415.V275076.R01.S.doc Timescale for action 30/01/06 2. 3. OP8 OP16 16 (2,i) 17 (2) Sch 4 (11) 12(1,a) 13(6) 17(1,a) 16(1,c) 30/01/06 30/01/06 4. OP18 30/01/06 5. OP24 01/05/06 6. OP26 13 (3) 01/03/06 Church View Nursing Home Version 5.1 Page 21 7. OP26 13 (3) 8. OP26 13 (3) 9. OP33 26 thoroughly cleaned. The registered provider is required to ensure that the area below the hand basin in the kitchen is cleaned and any pipe work covered. The registered provider is required to ensure that all kitchen tiles in poor condition be replaced. The registered provider is required to ensure that monthly unannounced visits are undertaken to the service and reports are sent to the local CSCI office. Requirement from the previous inspection held 1st November 2005 01/03/06 01/04/06 01/12/05 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 OP7 OP18 Good Practice Recommendations It is recommended that, in order to evidence practice, all care documentation be signed and dated by the person completing it. It is recommended that the adult protection procedure include reference to the local No Secrets in Swindon and Wiltshire document. Church View Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Chippenham Area Office Avonbridge House Bath Road Chippenham SN15 2BB 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 Nursing Home DS0000052415.V275076.R01.S.doc Version 5.1 Page 23 - 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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