Inspection on 21/08/07 for Church View (Residential Home) Limited

This inspection was carried out on 21st August 2007.

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 (Residential Home)... 03/11/09

Church View (Residential Home)... 05/08/08

Church View (Residential Home)... 20/06/06

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 (Residential Home) Limited Church Street Oswaldtwistle Lancashire BB5 3QA Lead Inspector Mrs Janet Proctor Unannounced Inspection 21st August 2007 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 (Residential Home) Limited DS0000066410.V343250.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 (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 3 SERVICE INFORMATION Name of service Church View (Residential Home) Limited Address Church Street Oswaldtwistle Lancashire BB5 3QA 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) 01254 381652 01254 239863 Church View (Residential Home) Limited Vacant Post Care Home 32 Category(ies) of Old age, not falling within any other category registration, with number (32) of places Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. The home is registered for a maximum of 32 service users, to include: Up to 32 service users in the category of OP requiring personal care. The care home should employ a suitably qualified and experienced manager who is registered with the Commission for Social Care Inspection. 20th June 2006 Date of last inspection Brief Description of the Service: Church View Care Home Oswaldtwistle was purpose built in 1988. It is a single storey building, with level access, situated in its own well-kept grounds. The home is in the centre of the town of Oswaldtwistle, close to all local amenities. Church View Care Home is registered to provide 24-hour personal care for up to 32 older people aged 65years and over. Accommodation is offered in single en-suite bedrooms. Communal rooms include 3 lounges and 2 dining rooms. The garden is easily accessible to all residents. The current fees charged at Church View are £320 to £360.50 per week. Additional charges are payable for hairdressing. A statement of purpose that had information about the home was available to prospective residents and their relatives on request. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. A key unannounced inspection, which included a visit to the home, was conducted at Church View Residential Home on the 21st and 22nd August 2007. No additional visits had been made since the previous inspection. On the day of the inspection there were 30 residents at the home. Prior to the visit the Registered Manager had submitted information in a preinspection questionnaire. This gave information that was used in the planning of the inspection. Surveys were sent out to residents, relatives and other professionals and one was returned from a resident. On the day of the inspection information was obtained from staff records, care records, and policies and procedures. Information was also got from talking to residents, the Deputy Manager, staff members and visitors. A tour of the building took place. Wherever possible the views of residents were obtained about their life at the home and their comments are included in the report. What the service does well: A thorough assessment was done before a resident came to live at Church View Residential Home. The manager then had all the information she needed to make a decision about whether the home could meet the needs of the resident or not. Residents spoken to praised the staff and said how well they were looked after. They said, “The staff are very good with me” and “They’re very kind”. The residents spoken to said they were happy at the home. They said, “It’s very good, I’m very happy here” and “It’s marvellous”. The survey returned said that this person always received the care and support that they needed. Visitors could come to the home at anytime and were made welcome. A resident said, “My family come and see me and they come in my room and we sit here. The staff always offer them a cup of tea”. The routines in the home were flexible and residents had control over what they did and when. Residents said, “I get up at about 6.30 am as I like to get up early. I go to bed when I’m ready. Usually about 9.00 pm but later if there’s something good on TV”, “I get up when I want to” and “I do what I want when I want. I get up about 6.00 am. Not because I’m forced to but because I always do.” The food served at the home ensured that a balanced diet was served and was to the liking to of the residents. They said, “ The food’s very good Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 6 You can have what you want”, “You get plenty to eat and drink” and “The food’s very good. The Cook can’t do enough for you and he’ll make you anything you ask for.” The survey returned said that this person always liked the meals at the home. Residents all had their own room and toilet and were happy with the accommodation. They said, “I like my room and I’ve made it very homely. I sit and watch the world go by” and “My room’s very nice, it’s got everything I need in it. I’ve my own toilet and a light by my bed.” The survey returned said that this person always found the home fresh and clean. The recruitment procedures were very thorough and made sure that people were properly checked before they came to work at the home. This protected residents. What has improved since the last inspection? What they could do better: A Statement of Purpose and a Service User’s Guide should be available to all prospective residents and anyone else interested in the home so that they have current and accurate information about the home. All residents should receive a copy of their terms and conditions of residency at the time they move into the home. This is so that there is no potential for misunderstandings to occur about what will be provided. Prospective residents should receive confirmation in writing that their needs can be met at the home so that they can be confident that they will get the right care. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 7 The plan of care for each resident must identify all the needs and tell staff precisely how they should meet these. This is so that staff are aware of all the needs and give the right care in the same manner. The plan of care must be reviewed so that the information in it is current and accurate. If a health assessment identifies that there is a risk, then the plan of care must tell staff how to reduce of mange this. This is to ensure that the health and well being of residents is protected. Accurate records of all medication administered to the resident must be kept. Other practices relating to the control of medications should be strengthened so that residents’ health and well-being is protected. Toiletries should not be left in bathrooms, this is to prevent them being used communally. Activities for residents should be recommenced so that their social and recreational needs are met. A resident said, “ There’s not a lot going on during the day. We used to have activities – lots of different things but that’s stopped because they’re doing the lounge up. I’ll be glad when it’s finished and we can do things again – it’s a bit boring now”. There should be details about the usual or preferred routine of residents in their plans of care so that staff know how they like to spend their day. This is of particular importance for those residents who are unable to make their wishes known. All staff must receive training in safeguarding adults so that they know what to do if they see, hear or suspect something is not right Ongoing maintenance of the home should continue to ensure that it remains a pleasant place for residents to live. Attention should be given to windows, repair or replacement of furniture, use of bathrooms and quality of lighting. There must be hand wash, paper towels and gloves available to staff working in the laundry so that they are protected from infection. All staff must receive training in safe working practices so that they remain aware of good practice and can protect the health and safety of residents and themselves. A system for reviewing and improving the quality of care should be established and maintained so that issues requiring attention are identified and can be acted upon in a timely manner. These systems should include obtaining the view of residents and relatives. Fire drills must be done so that each member of staff is involved at least once every 12 months so that it can be seen that they know what to do when the alarm sounds. Bedside rails must be checked to ensure that they fit correctly Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 8 so that accidents do not happen by the use of these. Denture cleaner tablets must only be used following a risk assessment to show that the resident can use these safely. All electrical equipment should be tested annually to ensure that it is safe for residents and relatives to use. 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 (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 9 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Outcomes Statutory Requirements Identified During the Inspection Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 10 Choice of Home The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2, 3 and 6. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Prospective residents did not have all the information they needed to make a decision about the home. Contracts were not issued at the point of moving into the home, which had the potential for misunderstandings to occur. Residents received an assessment so that their needs were known before they came to live at the home. EVIDENCE: A new Statement of Purpose had been written but the new Service User’s Guide had not yet been completed. The copy of the Statement of Purpose was not dated so it could not be certain that this was the latest copy. Some of the information in the Statement of Purpose was incorrect and this may lead to misunderstandings about what to expect from the home. The last inspection report was on file but was not readily available to prospective residents and relatives. This meant that they might not have had access to relevant information about the home. The survey returned said that this person had Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 11 received enough information about the home to make a decision if it was right for them. Not all residents whose records were examined had a contract, as these were given to residents one month after admission. All care home providers must give people personalised information about the fees and terms and conditions of their stay, to include accommodation, food and personal care. The information must include the method of payment of the fees and the person or persons by whom the fees are payable. This information should be provided, ideally earlier, but at the latest by the day the person moves into the care home. The survey returned said that this person had received a contract. There were copies of assessments on file for the three residents whose records were examined. These showed that the information had been obtained prior to admission. This information was used to form the basis of the initial care plan. The manager or deputy always went to do an assessment wherever practicable before the resident was admitted. There were no letters on file confirming that the needs of the resident could be met at the home. Therefore they could not be confident that they would get the right care they needed. Intermediate care was not provided at Church View residential home. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 12 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7, 8, 9 and 10. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Residents had a plan of care, but there was not enough detail in all of these to ensure that their health, personal and social care needs were known to staff and could be met by them. Medication practices did not fully protect residents’ health. Privacy and dignity was respected. EVIDENCE: The care records for three residents were examined. The plans of care did not give staff all the information they needed to meet their needs. One of the plans seen had not been reviewed since July 2006 so the information in it could not be sure to be current and accurate. One plan was not dated and signed so it could not be seen who had written this and when. Two of the residents did not have a photo so there was no means of ensuring they could be correctly identified by staff. One resident did not have an address for their next of kin so they would not be able to be contacted if they could not be reached by telephone. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 13 Risk assessments were done for health. These included the risk of developing pressure sores, the risk of falling, moving and handling needs and nutritional needs. In two of the plans the risk of falls was high, but did not tell staff how to manage this risk. Residents were registered with a GP and had access to other professionals. The District Nurse visited residents if they required dressings or other health input. There were records kept of medications ordered, received and returned to the Community Pharmacy. Staff who gave medications had either done or were in the process of doing medication training. One resident self –medicated. There was a risk assessment seen in the care plan for this. The resident had a locked cabinet for storage of her medication and staff made regular checks to see that these were being taken correctly. Recently admitted residents did not have a photograph for identification purposes. Any handwritten entries on the charts were signed and witnessed to reduce the risk of errors. When residents received a variable dosage of medication (either one of two tablets) this was not indicated. This meant that staff were not aware of how many they usually had. There was no criteria for ‘as required’ medication so this might not be given in a consistent manner. One chart examined had gaps in administration but no reason why these had been omitted. The balance of tablets left did not correspond with the amount received and given. Another chart had gaps for the administration of night medication but these had been removed from the blister pack. The storage of medications was secure. Oxygen cylinders were stored appropriately. There was a thermometer but no records of the room temperature were available so it could not be evidenced that the room was always at the right temperature. Not all of the eye drops were dated so it could not be seen when these were no longer to be used. Controlled Drugs were correctly stored and recorded. There was a Transiderm Nitro 5 patch which was loose and not named in the cupboard. There were some Temazepam 10 mg tablets in the cupboard that had not been used for some time. Personal care was carried out in private and staff were seen to knock on doors before entering. There were good relationships between residents and the staff. Toiletries were seen in bathrooms which means they may be used communally. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 14 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 12, 13, 14 and 15. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. The current lack of activities meant that residents’ social and recreational needs were not being fully met. The daily routines were flexible and meant that residents had choice and control over their lives. Residents received a balanced diet that was to their liking. EVIDENCE: Both staff and residents said that activities had not been done for some time due to the redecoration of the lounge area. One resident said that she missed the activities. The staff said that these would recommence once the decoration had been completed. The survey returned said that there were sometimes activities arranged that this person could take part in. The Statement of Purpose said that relatives and friends were encouraged to make regular visits. They could see their visitors in the privacy of their rooms or in the lounge. Residents spoken to said that they made choices about their life style. Not all of the plans of care for residents had information in about their preferred rising and retiring times to ensure that staff knew what their preferred routines were. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 15 Religious services were held. The care plans made a note of the resident’s religion and one seen said that she would like to be involved in Holy Communion. Residents spoken to said that the food served at the home was to their liking. The Cook had a list of the residents individual likes and dislikes and their preferred alternatives so that he could ensure that there was always something that they liked available. The menu was on display so that residents knew what would be served that day. A record was kept of the meals served so that it could be seen if residents were taking a balanced diet. There was sufficient food in stock and this included fresh fruit and vegetables. Night staff had access to all of the food so that they could make snacks if anyone was hungry in the night. The kitchen was clean and tidy. Records were kept of cooking, fridge and freezer temperatures. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 16 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 and 18. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. Resident were confident that their complaints would be listened to and acted upon. The lack of training in safeguarding adults meant that all staff might not know how to protect residents. EVIDENCE: There was a copy of the complaints procedure on display on the general notice board and in each bedroom. This gave details of who to contact and the relevant telephone numbers. The procedure did not give a time frame for completion, so anyone making a complaint did not know when they could expect a response. There were no details of the complaints procedure in the Statement of Purpose. Residents spoken to said that they were happy at the home and had no grumbles or complaints. The survey returned said that this person knew who to speak to if they were not happy and they knew how to make a complaint. No complaints had been made to the home. The Commission had received one concern that was dealt with over the telephone. There was a safeguarding adults procedure that was clear and easy to understand and follow. It gave contact numbers of relevant Agencies that would need to be contacted if there was an incident. There was a Whistleblowing procedure. This reassured staff that information would be confidential and it also gave them an external helpline number. Not all staff had receive training in safeguarding adults. A member of staff spoken to was aware of Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 17 what they should do if they saw, heard or suspected something was not right at the home. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 18 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 and 26. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. Residents were provided with a safe, clean and comfortable place to live. EVIDENCE: The premises were warm, clean, and tidy. The decor and furnishings were homely. The lighting in one of the lounges was reduced which might make if difficult for people to read in the lounge. All of the windows throughout the home were low enough for residents to sit and look out. However, some windows were ‘fogged up’, reducing the view for residents. All of the bedrooms had a lock to their door so that residents could protect their privacy. They all had their own toilet. Some residents had brought in items to personalise their bedroom and this made them look very homely. One bedroom had an ‘easylever’ bed side rail fitted. This was not connected correctly and may cause an accident to the resident. Some of the furnishing and fittings looked worn and need replacing. For example some trims and Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 19 handles were missing from cupboards and wardrobes. There was a Nurse call system with wander leads for those who couldn’t reach the wall point so they could call for staff if they needed them. Two of the shower room and bathrooms were being used for storage and this meant they could not be used by residents. There was a separate laundry room that had sufficient equipment. Although there was a sink there was no handwash, towels or gloves seen. This meant that staff may be at risk of infection. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 20 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 27, 28, 29 and 30. Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. There were sufficient staff on duty to meet residents’ needs. Recruitment procedures were thorough enough to protect residents. Not all staff had been provided with sufficient training to ensure they could competently undertake their work. EVIDENCE: There was a rota that had the name of staff and they hours they worked. There was sufficient staff on duty for the number of residents and their dependencies. There were ancillary staff employed every day. Staff spoken to said that the deployment of staff had improved since the new manager started. The survey returned said that there were always staff available when they needed them. There were through procedures for recruitment. The files of three new staff were examined. These showed that an application form with a full history of employment was completed and an interview done. Two references were obtained and a Criminal Records Bureau clearance done. There was proof of identity for the person. All staff were given a contract of employment and they received a copy of the code of conduct. Two staff members spoken to confirmed that their recruitment had followed correct procedures. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 21 An induction list was seen for two new staff. The information on this did not meet the Skills for Care common induction standards. This meant that the new staff may not be receiving all the initial training they needed to be able to do their work correctly. Not all staff had received training in safe working practices. Arrangements were being made for this. The staff spoken to said that the amount of training received had improved since the new manager started. There were 50 of the care staff with the National Vocational Qualification in care, which meant that they had been given the knowledge and skills to dot heir work. Other staff were enrolled on the course. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 22 Management and Administration The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 31, 33, 35 and 38 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 31, 33, 35 and 38. Quality in this outcome area is adequate. This judgement has been made using available evidence including a visit to this service. The home was managed by a competent and capable person. There were no systems for monitoring the quality of care delivered at the home, which meant that it could not be shown that the service was being run in the best interests of the residents. The health, safety and welfare of residents was not fully protected. EVIDENCE: A new manager had been employed. She was a Registered Nurse who had experience of working in care homes. She was doing the registered manager’s award and hoped to finish this early in 2008. Staff spoken to said that they felt well supported by the manager and felt confident in her abilities. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 23 The home had achieved the nationally accredited Investors in People award. There were no internal auditing systems to monitor the quality of the service and help improve outcomes for residents. An annual development plan to help focus aims for the next 12 months was not available. The had not been a survey of the views of residents and relatives for some considerable period of time. Residents and relatives meetings were not held. This meant that there was no formal way for residents and relatives to give their opinion on how the service was run. The manager held meetings with staff so that they could have their say about the home and the way it was run. There were policies and procedures for staff to refer to. These were not dated and there was no evidence of regular review. This meant that the information in them might not be current and accurate. There were three residents whose benefits were managed by the home. A record was kept of the amount received, the amount paid to the home and the amount due to the resident for their personal allowance. These were signed for by the resident when received. Some money was kept in the home on behalf of residents. This was kept in a secure place. There were records of the date, any money deposited, any money withdrawn, the balance, and the signature. Receipts kept of items purchased. Some of these were checked and the money held and the records were accurate. The fire safety equipment was checked and maintained. There was a Work based fire risk assessment. Recommendations had been made to improve fire safety but there was no evidence of the actions taken. Although the fire alarm system was tested weekly formal fire safety drills were not done. This meant that all staff did not get involved in fire drills and there was no way on knowing if they would act correctly when the alarm sounded. The portable electrical equipment had not been tested as the handyman had not received the training to do this. Therefore, residents and staff could not be confident that electrical equipment was safe to use. There were records to show that other equipment and appliances were serviced regularly. Steredent was seen in some rooms and there was no evidence that these residents were safe to use it. As these were not locked other residents may have access to them. Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 24 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 2 2 2 X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 2 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 2 X X X X X X 3 STAFFING Standard No Score 27 3 28 3 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X 3 X X 2 Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 25 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 Care plans must provide detailed information about needs and how they are to be met so that staff know what they have to do. (Previous timescale of 27/10/06 not met) The plans of care must be kept under review so that the information in them is a current and accurate description of the residents’ needs. When a health risk has been identified there must be a care plan in place to tell staff how to manage or reduce the risk. (Previous timescale of 30/12/05 not met.) Accurate records of all medication administered to the resident must be kept so that their health and well-being is protected. All staff must receive training in safeguarding adults so that they know what to do if they see, hear or suspect something is not right All bedside rails must be checked to ensure that they are correctly DS0000066410.V343250.R01.S.doc Timescale for action 31/10/07 2 OP7 15(2) 30/11/07 3 OP8 12(1)(a) (b) 31/10/07 4 OP9 13(2) 31/08/07 5 OP18 13(6) 31/12/07 6 OP19 13(4)(c) 31/08/07 Church View (Residential Home) Limited Version 5.2 Page 26 7 OP26 13(3) 8 OP30 18(1)(c) 9 OP38 23(4)(e) 10 OP38 13(4)(c) fitted so that they do not cause an injury to the resident. There must be hand wash, paper towels and gloves available to staff working in the laundry so that they are protected from infection. All staff must receive training in safe working practices so that they have the skills and knowledge to do their work properly. Fire drills must be done so that each member of staff is involved at least once every 12 months so that it can be seen that they know what to do when the alarm sounds. Denture cleaner tablets must only be used following a risk assessment to show that the resident can use these safely. 31/08/07 31/12/07 30/11/07 31/08/07 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 Refer to Standard OP1 Good Practice Recommendations A Statement of Purpose and a Service User’s Guide should be available to all prospective residents and anyone else interested in the home so that they have current and accurate information about the home. A copy of the latest inspection report should be available so that residents and others have access to relevant information about the home. All residents should receive a copy of their terms and conditions of residency at the time they move into the home so that there is no potential for misunderstandings to occur about what will be provided. Prospective residents should receive a letter telling them whether their needs could be met at the home so that DS0000066410.V343250.R01.S.doc Version 5.2 Page 27 2 OP2 3 OP29 Church View (Residential Home) Limited 4 OP7 they can be confident that they will receive the right care. The plan of care should be signed and dated so that it is obvious who has written this and when. There should be a record of the address of the next of kin so that they can be contacted in an emergency. There should also be a photograph of the resident so that they can be correctly identified by all staff. All residents should have a photograph on their medication chart so that staff can correctly identify them and reduce the risk of medication being administered to the wrong resident. When residents are prescribed either one or two tablets staff should indicate how many they have been given so that consistency is maintained. Instructions stating when medication prescribed as required should be given so that it is given in a consistent manner. There should be records of the temperature of the storage area so that it can be seen that medications are stored correctly. Eye drops should be dated when opened so that it can be seen when these are to be disposed of. Medication no loner required should be returned to the Community Pharmacist for destruction. Each resident should have their own toiletries. These should not be left in bathrooms to prevent them being used communally. Activities for residents should be recommenced so that residents’ social and recreational needs are met. There should be details about the usual or preferred routine of residents in their plans of care so that staff know how they like to spend their day. The complaints procedure should tell people the latest by which they can expect a response to any issue brought to the attention of the Manager. The lighting in all areas of the home should be sufficient for residents’ needs. Windows should be repaired or replaced so that residents’ view from these is not obscured. Furniture should be repaired or replaced when it becomes 5 OP9 6 7 8 9 10 OP10 OP12 OP14 OP16 OP19 Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 28 worn. Bathrooms should be cleared of items stored in them so that residents can make use of the facilities. There should be systems to audit the quality of care provided at the home so that any deficiencies can be identified and acted upon. There should be an annual development plan that sets out the proposed development of the home for the next 12 months. The views of residents and relatives should be obtained on a regular basis so that these can be taken into consideration. Policies and procedures should be reviewed at regular intervals so that the information in them is current and accurate. All portable appliances should be tested each year to ensure they are safe for use. 11 OP33 12 OP38 Church View (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 29 Commission for Social Care Inspection Lancashire Area Office Unit 1 Tustin Court Portway Preston PR2 2YQ 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 (Residential Home) Limited DS0000066410.V343250.R01.S.doc Version 5.2 Page 30 - 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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