CARE HOMES FOR OLDER PEOPLE
CHURCH WALK HOUSE Church Walk Childs Hill London NW2 2TJ
Lead Inspector Jane Ray Announced 11 April 2005 at 09.30am The Commission for Social Care Inspection aims to: • • • • Put the people who use social care first Improve services and stamp out bad practice Be an expert voice on social care Practise what we preach in our own organisation Reader Information
Document Purpose Author Audience Further copies from Copyright Inspection Report CSCI General Public 0870 240 7535 (telephone order line) This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. Extracts may not be used or reproduced without the express permission of CSCI www.csci.org.uk Internet address This is a report of an inspection to assess whether services are meeting the needs of people who use them. The legal basis for conducting inspections is the Care Standards Act 2000 and the relevant National Minimum Standards for this establishment are those for Care Homes for Older People. They can be found at www.dh.gov.uk or obtained from The Stationery Office (TSO) PO Box 29, St Crispins, Duke Street, Norwich, NR3 1GN. Tel: 0870 600 5522. Online ordering: www.tso.co.uk/bookshop This report is a public document. Extracts may not be used or reproduced without the prior permission of the Commission for Social Care Inspection. CHURCH WALK HOUSE Version 1.10 Page 3 SERVICE INFORMATION
Name of service Church Walk House Address Church Walk, Childs Hill, London NW2 2TJ Telephone number Fax number Email address Name of registered provider(s)/company (if applicable) Name of registered manager (if applicable) Type of registration No. of places registered (if applicable) 020 7794 2144 020 77794 2460 Rev John Wainwright for Hendon Old Peoples Housing Society Pauline Pope Care Home 42 Category(ies) of Dementia over 65 years of age (42) and old age registration, with number not falling within any other category (42) of places Dementia under 65 years (2) CHURCH WALK HOUSE Version 1.10 Page 4 SERVICE INFORMATION
Conditions of registration: 1 Limited to 42 service users who are elderly and may have dementia. 2 Two specific service users who are currently resident in the home and under 65 years of age can reside in this home. This condition will need to be reviewed when either one of these vacate the home. Date of last inspection 2 March 2005 Brief Description of the Service: Church Walk House is registered to provide personal care and support for 42 older people who may also have dementia. The home is operated by a charitable organisation, the Hendon Old Peoples Society, which manages the home through a management committee board of governors. The accommodation is provided in a building that used to be the vicarage. The building is on three floors. In the basement is the kitchen and laundry. On the ground floor is the main lounge, dining room, smokers lounge and a number of bedrooms. On the first floor are the rest of the bedrooms, a quiet lounge and the offices. Six of the bedrooms are shared and the rest are single. There are disabled accessible bathrooms and showers on both floors. There is a lift available in the home. There is a beautiful garden at the rear of the home. The staff team consists of a manager, a senior assistant manager, three assistant managers, two senior carers and a team of carers. There is also a team of ancillary staff including cleaners, cooks and laundry assistants. In the morning there are between 6-8 care staff and in the afternoon there are 5 care staff and 3 waking staff at night. The service also has a team of staff who organise a wide range of activities. CHURCH WALK HOUSE Version 1.10 Page 5 SUMMARY
This is an overview of what the inspector found during the inspection. The inspection took place over 8 hours and was the annual announced inspection. The manager assisted with the inspection. A tour of the premises took place and the staff and care records were inspected. The inspector met all of the residents and was able to speak in more depth to twelve residents. The inspector also met all of the staff on duty and interviewed two recently recruited care staff. During the inspection the inspector met one relative. In addition the inspector received fifteen comment cards from the service users and five from relatives giving written feedback on the service. What the service does well: What has improved since the last inspection?
Since the last inspection the manager has ensured that all the staff working in the home have the necessary Criminal Record Bureau checks. The manager has also prepared questionnaires as part of the quality assurance exercise that have gone to the residents and relatives to receive feedback on the quality of the service and identify areas for improvement. CHURCH WALK HOUSE Version 1.10 Page 6 What they could do better: Please contact the provider for advice of actions taken in response to this inspection. The full report of this inspection is available from enquiries@csci.gsi.gov.uk or by contacting your local CSCI office. CHURCH WALK HOUSE Version 1.10 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS
Choice of Home (Standards 1–6) Health and Personal Care (Standards 7-11) Daily Life and Social Activities (Standards 12-15) Complaints and Protection (Standards 16-18) Environment (Standards 19-26) Staffing (Standards 27-30) Management and Administration (Standards 31-38) Scoring of Standards Statutory Requirements Identified During the Inspection CHURCH WALK HOUSE Version 1.10 Page 8 Choice of Home
The intended outcomes for Standards 1 – 6 are: 1. 2. 3. 4. 5. 6. Prospective service users have the information they need to make an informed choice about where to live. Each service user has a written contract/ statement of terms and conditions with the home. No service user moves into the home without having had his/her needs assessed and been assured that these will be met. Service users and their representatives know that the home they enter will meet their needs. Prospective service users and their relatives and friends have an opportunity to visit and assess the quality, facilities and suitability of the home. Service users assessed and referred solely for intermediate care are helped to maximise their independence and return home. The Commission considers Standards 3 and 6 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 3,4,5 The admissions process is working well and prospective residents are assessed and then introduced in an appropriate manner to the home where they can be confident that their needs can be met. These standards were met. EVIDENCE: The case notes of the two new residents admitted to the home since the last inspection, were inspected and these contained assessments prepared by an appropriate care professional and assessments completed by the home. These also indicated that the service users had care needs that were appropriate to be met by the home. The two recently admitted residents were spoken to during the inspection. One said she had been invited to visit the home before she moved in. She also explained that she had found it difficult adjusting to living in the home but was given plenty of support and encouragement by the staff and is now very happily settled. The staff were observed during the inspection supporting the residents and all appeared to have a good understanding of their individual needs. This was also CHURCH WALK HOUSE Version 1.10 Page 9 reflected in the comments during the inspection from the residents and visitors who all said they were satisfied with the standard of care. CHURCH WALK HOUSE Version 1.10 Page 10 Health and Personal Care
The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 7,8,9,10 and 11 The standards were partly met as residents health, personal and social care needs appeared to be provided, but the standard of the information recorded in their individual care plans made it hard to substantiate that all the necessary support was actually being implemented. EVIDENCE: The case notes for four residents who had lived in the home for over four months were inspected. The care plans all contain an assessment updated by the home. Each resident has two or three individual care plan goals. Two of the residents had not had their care plan goals updated for over a month and in one case it was six months since the care plan had been updated. None of the case notes had a record of any of the four residents having a care plan review meeting with their care manager or relatives in the previous year. The care plan documentation contained sections where healthcare input could be recorded. All of the four residents had a record of seeing the GP but one resident had no record of the reason and outcome for the appointment. Three of the four residents had no clear record of when they last saw the optician, dentist or chiropodist, which made it difficult to see if and when they had received this input.
CHURCH WALK HOUSE Version 1.10 Page 11 The residents had a record of seeing specialists as required, for example one resident had seen the speech and language therapist for advice about eating and swallowing difficulties. The four service users all had individual moving and handling risk assessments that had been regularly updated. It was observed that a number of residents use wheelchairs for moving around the home. Two wheelchairs were seen being used without the footrests. The wheelchairs were also observed to be dirty and in need of proper cleaning. The home uses the Boots medication administration system. The medication and administration record were inspected for the four service users and was in order. The residents were all well groomed and dressed. One resident said “they take very good care of you” and a relative said “the standard of care is very high”. Another resident said that the staff “help keep her alive”. CHURCH WALK HOUSE Version 1.10 Page 12 Daily Life and Social Activities
The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 12,13,14 and15 The resident’s are offered an excellent range of activities that meets their different interests and needs. The food is a very high standard and presented in an attractive manner. The standards were met. EVIDENCE: The activity programme was inspected and is varied and offers activities throughout the day. Some activities are facilitated by the staff employed by the home and others use external professionals such as art therapy sessions. Two activities were observed and the residents were seen to be enjoying the session. Some of the activities are helpful for people with dementia enabling them to retain their mental skills. The feedback from the comment cards returned by relatives and visitors all said that they are made welcome in the home at anytime and can see their relative or friend in private if they wish to do so. The food that is prepared in the home uses fresh produce and is nutritious and wholesome. There is a choice of meals available. The residents sit in two dining areas. There is a main dining room and then a second smaller dining area for the residents who need a lot of assistance. The presentation of the food in the main dining area was very attractive with vegetables in a separate bowl so the residents can serve themselves. In the small dining area the staff were
CHURCH WALK HOUSE Version 1.10 Page 13 observed supporting the residents in a discreet and unhurried manner speaking to them throughout the meal. All the residents who spoke to the inspector said how much they enjoyed their food and how their personal preferences are always met. CHURCH WALK HOUSE Version 1.10 Page 14 Complaints and Protection
The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 18 The home has the necessary procedures and staff training in place to protect the residents from abuse. EVIDENCE: The staff training records showed that staff have received training on adult protection issues and there is more training planned later in the year for new staff to attend. The home looks after the financial affairs of the majority of the residents. The financial details were inspected for four service users. There were clear records of expenditure and receipts available. Residents who are able to hold and manage their own money are encouraged to do so. CHURCH WALK HOUSE Version 1.10 Page 15 Environment
The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 19,20,21,22,23,24,25 and 26 Church Walk House is an old building with rather an institutional layout. Despite these limitations there has been a great deal of work to create a homely and comfortable environment and the limited resources have been spent wisely to enhance the areas of the home used by the residents. These standards are met. EVIDENCE: There are two staff employed to maintain the home and the building and grounds were kept safe, tidy and attractive. There is a range of communal space including a main lounge, a quiet lounge and a small smoking sitting room. There are adequate toilets, bathrooms and showers throughout the home that are disabled accessible. The bathrooms on the first floor were temporarily out of action due to the recent fire and there are plans to bring these areas back into use.
CHURCH WALK HOUSE Version 1.10 Page 16 The home has a number of adaptations including a shaft lift, staff call system, ramps and hand-rails. There are still six shared bedrooms and these have curtains to maintain privacy. The bedrooms are lockable and each room also has a lockable drawer to store any valuables. The radiators on the rooms are thermostatically controlled and the radiators have guards. The home was spotlessly clean and tidy. The laundry is well equipped with appropriate industrial machines that can be set to different temperatures as required. Personal laundry is labelled to ensure it is returned to the correct person and shirts are all ironed as necessary. CHURCH WALK HOUSE Version 1.10 Page 17 Staffing
The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,28,29 and 30 The standards are partly met as the home has a reasonably stable team of staff and they are enthusiastic about working positively with the residents to give them a good quality of life. The manager does however need to ensure all the necessary recruitment information is available and that each member of staff has an individual training record so that they can all be enabled to have the necessary training. EVIDENCE: The staff files for three staff recruited in the previous two months were inspected. They all had a Criminal Record Bureau check and two written references. Two of the staff did not have a copy of their passport available in their records and for one member of staff there was no record of authorisation to work in this country. There was no recorded induction available for any of the new staff although two of the staff were interviewed during the inspection and said that they had shadowed another member of staff for a week and had been shown how everything operates in the home. The staff records were inspected for four staff who had been working in the home for over a year. They all had a Criminal Record Bureau check. There was no record for each member of staff stating what training they had received and when this had taken place and so it was not possible to say what training they required or needed to be updated. The inspector was pleased to note that seven staff had completed their NVQ level 2 or 3 training.
CHURCH WALK HOUSE Version 1.10 Page 18 It was positive to observe how well the staff communicated with the residents and to see that this also extended also to the ancillary staff who work in the home. The inspector was concerned about the approach of one member of staff. During the inspection all the other staff were helpful and supportive of the process. This one member of staff had a very hostile and aggressive approach when asked a few questions during the inspection. This was in front of other members of staff and residents. The inspector later found out that this member of staff had recently been suspended whilst an incident was investigated and part of this investigation had centred on her approach to other people. The inspector is concerned that this member of staff could extend her aggressive approach to the residents and relatives and feels that the manager supported by the management committee should review the suitability of this member of staff to work in this setting. CHURCH WALK HOUSE Version 1.10 Page 19 Management and Administration
The intended outcomes for Standards 31 – 38 are: 31. 32. 33. 34. 35. 36. 37. 38. Service users live in a home which is run and managed by a person who is fit to be in charge, of good character and able to discharge his or her responsibilities fully. Service users benefit from the ethos, leadership and management approach of the home. The home is run in the best interests of service users. Service users are safeguarded by the accounting and financial procedures of the home. Service users’ financial interests are safeguarded. Staff are appropriately supervised. Service users’ rights and best interests are safeguarded by the home’s record keeping, policies and procedures. The health, safety and welfare of service users and staff are promoted and protected. The Commission considers Standards 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 31,32,33,36 and 38 The standards were partly met as the home has a manager who is leading and directing the service in a very competent and positive manner. The manager does however need to ensure that systems for reviewing the performance of the home have been fully implemented. EVIDENCE: The inspector spoke to the manager, staff, service users and visitors and the positive outcomes reflected the skills and experience of the manager. Two staff commented that they “felt very well managed and supported”. A number of the service users wanted to specifically praise the manager and the work she undertakes. The staff supervision records were also inspected for the four staff. None of the staff had received regular supervision. The assistant managers undertake some of the supervision and kept the records in their personal lockers so they could not be accessed by the manager if required.
CHURCH WALK HOUSE Version 1.10 Page 20 The manager was able to show the inspector a copy of the quality assurance questionnaires that had gone out to the service users and relatives. Questionnaires had not yet been developed for care professionals such as the GP, district nurses, care managers etc. The results of these questionnaires had not yet been received or collated. The records of weekly fire alarm checks and fire drills were inspected and these have taken place as required. The maintenance certificates were checked for the water system, nurse call, lift, hoist, electrical systems and fire appliances and these were all in place. The gas landlord safety certificate had expired and the necessary servicing of equipment needs to take place. The inspector was concerned about whether the electrical installation check had been carried out by an appropriately qualified electrician particularly following the two fires caused by electrical light installations in the last year. The staff training records were inspected for four staff who had been in post for over a year. One had no record of having fire safety training and one had no record of moving and handling training. Two staff had received training more than three years previously and this needs to be updated. CHURCH WALK HOUSE Version 1.10 Page 21 SCORING OF OUTCOMES
This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. Where there is no score against a standard it has not been looked at during this inspection. The scale ranges from:
4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable
CHOICE OF HOME ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score x x 3 3 3 N/A HEALTH AND PERSONAL CARE Standard No Score 7 1 8 1 9 3 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 x 15 4
COMPLAINTS AND PROTECTION 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 1 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x 3 3 3 2 x x 1 x 1 CHURCH WALK HOUSE Version 1.10 Page 22 NO Are there any outstanding requirements from the last inspection? STATUTORY REQUIREMENTS This section sets out the actions which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1. 2. Standard 7 7 Regulation 15 15 Requirement The residents care plan must be reviewed once a month. The resident must be supported to have an annual care plan review meeting with their care manager. A record must be kept of when the residents have seen the dentist and optician to ensure these checks happen at least once a year. If the resident chooses not to have these checks then this must be recorded. The staff must ensure that the footrests are used on the wheelchairs. The wheelchairs must be regularly cleaned. All the staff files must contain a copy of the member of staffs I.D and where appropriate a copy of the authorization to remain and work in the country. All new staff must have a recorded induction training programme. All staff must have an individual training reocord including copies of their training certificates. The manager with the support of
Version 1.10 Timescale for action 31/5/05 31/7/05 3. 8 12 30/6/05 4. 5. 6. 8 8 29 12 12 17 30/4/05 30/4/05 31/5/05 7. 8. 9. 30 30 32 18 18 12 31/5/05 30/6/05 31/5/05
Page 23 CHURCH WALK HOUSE 10. 11. 36 36 18 18 12. 33 24 13. 14. 38 38 13 13 15. 38 13 the management committee must review the approach of a named member of staff to decide if they should work with vulnerable adults. All the staff must receive regular inidividual supervision at least every two months The supervision records must be stored so that they can be accessed by the manager as required. The manager must extend the quality assurance excercise to include the views of other care professionals associated with the home. The results from the returned questionnaires must be collated and an action plan prepared. The annual gas landlord safety check must take place as a matter of urgency. The manager must ensure that the company carrying out the electrical installation check has the appropriate skills and qualifications. All the staff must have food hygiene, first aid, moving and handling and fire safety training. This training must also be updated where necessary. 31/5/05 31/5/05 31/7/05 30/4/05 30/4/05 31/7/05 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. Refer to Standard Good Practice Recommendations CHURCH WALK HOUSE Version 1.10 Page 24 Commission for Social Care Inspection Solar House 1st Floor, 282 Chase Road Southgate London N14 6HA National Enquiry Line: 0845 015 0120 Email: enquiries@csci.gsi.gov.uk Web: www.csci.org.uk
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