Inspection on 16/06/06 for Church Walk House

This inspection was carried out on 16th June 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 Walk House 07/04/09

Church Walk House 04/07/08

Church Walk House 29/05/07

Church Walk House 08/12/05

Church Walk House 11/04/05

Church Walk House 06/10/04

Church Walk House 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 Walk House Church Walk Childs Hill London NW2 2TJ Lead Inspector Wendy Heal & Susan Shamash Key Unannounced Inspection 16th June 2006 10:30 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 Walk House DS0000010421.V292035.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 Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Church Walk House Address Church Walk Childs Hill London NW2 2TJ 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) 020 7794 2144 020 7794 2460 Hendon Old Peoples Housing Society Mrs Anne Pauline Pope Care Home 42 Category(ies) of Dementia (2), Dementia - over 65 years of age registration, with number (42), Old age, not falling within any other of places category (42) Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. Limited to 42 service users who are elderly and may have dementia. 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. 8th December 2005 Date of last inspection 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 are 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. The Purpose and Function Document and last inspection report are available on the notice board at the entrance of the home. The fees are four hundred and fifty pounds. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection and took place as part of the inspection programme. Compliance was checked against key standards and took approximately six hours. The inspectors undertook a tour of the building and spoke with service users and members of the staff team. The inspectors gained further information by an inspection of the documentation kept in the home, including care plans. The manager assisted the inspectors throughout the day. The inspectors would like to thank the service users present during the inspection, the manager, staff and service users for their openness and participation. What the service does well: What has improved since the last inspection? What they could do better: Service users must have their annual care plan review meeting to ensure their views are heard and changing needs are met. The manager must ensure that all staff employed have a valid CRB obtained to protect service users from abuse. Care plans must be up to date with clear goals to ensure service users needs can be met. Risk assessments must be completed in relation to the use of bedsides to minimise harm to service users. Manual handling assessments must identify how many staff is needed to ensure the service users are safe and ensure the service users’ needs are met. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 6 Medication must be clearly recorded on the medication chart. Medication must be ordered well in advance to ensure supplies do not run out. Medication procedures must be in place to identify that if a service user is running short of medication, then medication can be ordered without delay to safeguard the service user from harm. Complaints must be fully recorded in the complaints book to ensure accurate recording procedures. Fire notices must be completed to inform staff and service users of the action to be taken in the event of a fire. Staff must have an individual training record to encourage their professional development. Staff must receive regular supervision to ensure a professional, consistent approach and adequate support is offered to staff. Supervision records must be stored so that they can be accessed by the manager, to enable monitoring of supervision to be undertaken. A quality audit must take place to obtain feedback in how the service can be improved and where it is succeeding. Chemicals must be stored appropriately to ensure the safety of service users. The manager must ensure all serious incidents are reported to the Commission to meet current legislation. The provider must ensure that the Commission is informed of the arrangements to be made in relation to who will manage the home for the period the home does not have a manager, to ensure the professional running of the home. 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 Walk House DS0000010421.V292035.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 Walk House DS0000010421.V292035.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): 3 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before a visit to this service. Prospective and existing service users’ needs are assessed by the home when they are first admitted to assist staff in meeting their needs. EVIDENCE: The files of three service users were examined. It was evident from these files that the home had received a copy of assessments from social workers and reports from health professionals. In a discussion with the inspector the manager confirmed that new service users are also assessed by the home. Two relatives stated in a feedback card that they visited the home on two occasions before a new relative was admitted to the home. It was clear from the feedback provided that the new service user had an opportunity to visit the home at different times to see the facilities and to meet with the people who live and work at the home. During the inspection the inspector noted that staff seemed knowledgeable in relation to the service users individual needs and all residents spoken with were happy with the care provided. The home does not provide intermediate care. Church Walk House DS0000010421.V292035.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, 8, 9, 10 Quality in this outcome area is poor. The judgement has been made from evidence gathered both during and before the visit to this service. Service users care plans did not all contain clear goals and had not been updated on a monthly basis which means that service users’ needs cannot be fully met. Service users had not all had a care plan review meeting with their care manager to ensure their changing needs are acknowledged and acted upon. Not all service users’ review notes were signed and dated which would assist accurate recording of service users’ information. Service users’ risk assessments must be improved to ensure that service users’ needs are met and their wellbeing is safeguarded. Service users are appropriately supported to address their health care needs, including referral to external healthcare professionals. Service users wheelchairs are now being used with footrests in place. Service users are not fully protected by the home’s medication policy and procedures. Service users spoken with appreciated being treated with respect by the home. EVIDENCE: The care notes for seven service users who live in Church Walk were inspected. The care plans did not all contain clear goals and had not been updated on a Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 10 monthly basis, indicating that service users’ needs are not fully met. requirement has been made in relation to this. A Not all service users had been supported to have an annual care plan review meeting with their care manager to ensure service users’ changing needs are acted upon and their views are heard. A requirement has been restated. The service users had seen the chiropodist, optician and general practitioner. Records of appointments and input from specialists were up to date which ensures that service users’ health care needs are being monitored. Service users’ risk assessments showing potential risks for service users are being reviewed but not all of them are up to date. Risk assessments do not include all relevant areas to ensure that service users’ health and safety is safeguarded and service users’ needs are met. Risk assessments are needed regarding the use of bed -sides and other ways that may minimise the risk of service users falling from their beds. One identified service user who suffers from oedema in their feet has no risk assessment completed indicating that the identified risks to this service user are not minimised. This same service user has a manual handling assessment, which did not identify how many staff are needed to meet the service user’s needs. Requirements have been made in relation to all of the above. The home uses the Boots Medication Administration System. The medication administration records were inspected. The inspectors noted that there were some gaps in the recording of medication administered on the MAR sheets and medication has not been appropriately signed for, which means that service users are not protected adequately by the medication recording system to ensure their well being is not put at risk. The inspector noted that some medicines had run out prior to the new batch of medication arriving, especially Lactulose, Gaviscon and some painkillers. Medicines must be ordered well in advance to ensure that supplies do not run out for service users, which would put their health, safety and well being at risk. The home must ensure procedures are put in place to identify that if a service user is running short of an identified medicine, that this medication can be obtained without delay. Requirements have been made in relation to the above. The medication was found to be stored appropriately in a locked medication cabinet, which ensures that medication is stored in a professional manner and safeguards the health of service users. It is good practice for a copy of the prescriptions to be attached to the MAR sheet for clarification. This was a good practice recommendation made at the last inspection, which has been restated at this inspection. Adequate records were maintained of the room temperature for the room in which medicines are stored. Records indicated that the temperature did not Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 11 exceed 25ºC, which means that medication does not deteriorate and harm service users. This was a requirement made at the last inspection, which has now been met. The inspectors recommends that the general practitioner is consulted regarding medicines which are only given when the service users wish – to see if these medicines can be changed to PRN to assist with the professional recording of medication which further protects service users from medical errors being made and assists good practice. A good practice recommendation has been made. The service users spoken with were all very happy with the care provided. All of the service users appearance was of a high standard which promotes their self- image. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 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 the following standard(s): 12, 13, 14, 15 Quality in this outcome area is good. The judgement has been made from evidence gathered both during and before the visit to this service. Service users benefit from various social and recreational activities organised by the home meeting their needs and preferences. Family and visitors are welcome to the home, which service users appreciate and this benefits service users’ emotional wellbeing. Service users are encouraged to exercise as much choice and control over their lives as they can to maximise their independence. Service users benefit from excellent quality meals, which are beneficial to their health. EVIDENCE: The activity programme was examined and offers a range of activities throughout the day to service users. The inspectors spoke with the activities organiser who described some of the activities arranged with service users. These include a clothes show, world cup viewing, drama therapy, attending two Lyons Club parties, trips out to the local shops, various clothing outlets and Brent Cross. This means that service users are supported to access a wide range of community- based activities which are linked to their needs and preferences and was evidenced by observations on the day of the inspection. Church Walk does not own its own vehicle to assist with community activities. The service users use Dial a Ride, taxi card schemes and Brent Cross Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 13 community transport. The inspectors recommend that the activities organiser undertake the Midas training so that she can drive the hired minibuses and therefore increase her flexibility in relation to service users, which will improve the service users’ quality of life. A good practice recommendation has been made in relation to this. Service users are supported to participate in religious services of their choice. Documentary evidence of this was seen in some service users’ files and in discussion with the Priest (and responsible individual for the home). Service users are supported to maintain contact with their friends and family, which, benefits their emotional well being. The food seen in the home was fresh produce. It was of good appearance, nutritious and wholesome. The service users’ dietary needs are being met which benefits their health and wellbeing. The presentation of the food was excellent with fresh fruit and vegetables available. The cook showed the inspectors the list of service users’ likes and dislikes and service users’ personal choices were identified, which means service users wishes’ are being respected, which increases their self-esteem and quality of life. On the day of the inspection the kitchen was clean and tidy and well organised. The fridges were inspected and food was stored appropriately and was within its use by date. The food stored within the fridge was properly labelled minimising risk of ill health to service users. Service users benefit from a mixed staff team who bring a range of different ideas to the home in terms of food preparation. This benefits service users as they have access to different types of food than they may otherwise experience. The service users have the use of two dining rooms; one of these is smaller and more appropriate for those service users who need more assistance. The service users spoke with the inspectors and expressed their satisfaction with the food available, saying ‘it was excellent’. The inspectors ate a meal at the home and were impressed with the standard of food and its presentation. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 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 the following standard(s): 16 – 18 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before a visit to this service. There is written information available regarding the complaints process including information on who to contact if a complainant is not satisfied with the response from the home. Service users are protected by an adult protection policy and guidance is available for staff on how to respond to allegations or disclosures of abuse if these should be made. EVIDENCE: The home has a complaints book available in the manager’s office and a visitors book is kept by the front door with a copy of the complaints procedure available for service users and visitors to view. The complaints book did not refer to the most recent complaint referred to the Commission for Social Care Inspection. The manager confirmed that this complaint was too detailed and had been filed separately. This complaint had been clearly documented. However, the manager must ensure that all complaints are identified in the complaints book and if information is filed separately this is noted in the complaints book to ensure adequate recording is maintained. A requirement has been made in relation to this. The home had an adult protection procedure and evidence was seen that staff had undertaken adult protection training. The home also had a copy of the local authority adult protection procedure for the authority the home is located in, which means staff have greater knowledge in relation to how to deal with adult protection procedures should they arise, including the specified means of alerting the local authority which assists staff to protect service users from abuse. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 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 the following standard(s): 19, 20, 21, 22, 23, 24, 25, 26 Quality in this outcome area is adequate. The judgement has been made from evidence gathered both during and before the visit to the service. The standard of the environment within the home is good providing service users with an attractive, homely, comfortable place to live. Appropriate facilities are provided to enable service users to have access to comfortable indoor and outdoor communal facilities, which they can then enjoy. The bathroom showers and washing facilities are suitable for people with disabilities and ensures their needs are met. Service users have the specialist equipment they require to maximise their independence. Service users’ bedrooms are personalised to their own individual taste and suit their needs. The home is clean, pleasant and hygienic which ensures the health, safety and well being of service users and staff. Improvements need to be made to ensure service users live in a safe environment. Fire notices must contain all relevant information to indicate where service users need to meet in the event of fire to ensure service users’ health and safety. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 16 EVIDENCE: During a tour of the building, Church Walk showed a reasonable standard of cleanliness, which ensures the health, safety and well being of service users and staff. The home was reasonably decorated and well maintained and the service users’ bedrooms were clean and tidy and personal, and contained their own belongings, which mean service users live in a pleasant environment. Church Walk has adequate facilities in terms of communal space provided which allows service users ample personal space to undertake activities of their choice. The bathroom, showers and toilets are accessible to those with disabilities, which ensures their personal needs are met. However, one staff member spoken with said, “there need to be more toilets available to adequately meet the needs of service users.” The home is fully adapted including internal rails, ramps, lift and call system which means there are appropriate facilities to enable service users with a physical disability to access the garden and all other areas of the home. The laundry is well equipped with adequate machinery to enable the laundering of service users’ clothes to be fully met, to ensure their personal appearance is maintained to an acceptable standard. The fire safety notices must contain all relevant information to ensure service users and staff knows what action to take in the event of a fire. A requirement regarding this has been restated. At the time of the inspection fire exits were clear. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 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 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, 28, 29, 30 Quality in this outcome area is poor. The judgement has been made from evidence gathered both during and before a visit to this service. The home has a stable staff team in sufficient numbers to support the current number of service users accommodated and to assist in meeting there assessed needs. Service users are not fully protected by the home’s recruitment policy and improvements are required in this area. Training opportunities for staff exist to assist them in meeting service users’ needs. However, the record of staff training must be improved to ensure adequate training records exist for staff to prove that service users’ needs are met and the staff members’ own professional development is recorded. EVIDENCE: A staff rota for the home was inspected and found to be satisfactory, with staff on duty during the inspection matching those recorded on the rota, which meant there were adequate staff on duty to meet the needs of service users. It was noted that the staff group at the home was relatively stable with the majority of the existing staff having worked in the home for a number of years, which increases the sense of security for service users. A number of staff had completed their NVQ Levels 2 and 3, which ensures adequate qualified staff are available to support service users. The staff had also undertaken fire safety training, food hygiene training, medication training and a four- day first aid course to expand their knowledge and improve the quality of care provided to service users. The manager needs to ensure that there is a clear record of training to show the training that staff had received Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 18 and when this has taken place to assist staff development and ensure adequate recording. A requirement has been restated accordingly. Staff files were inspected and one staff member did not have the necessary Criminal Records Bureau checks and Protection of Vulnerable Adults confirmation to ensure service users are protected from abuse. An immediate requirement was therefore made at this inspection. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 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 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): 31, 33, 36, 38 Quality in this outcome area is poor. The judgement has been made from evidence gathered both during and before the visit to the service. The registered manager is in the process of leaving the organisation and there is therefore a need to recruit a manager with the required qualifications and training to ensure that service users benefit from the management of the home and the philosophy of care provided. The management of the home needs to be reviewed to ensure that necessary tasks are addressed in the interim period of recruitment to ensure the needs of service users are met and the home is managed effectively. The views of service users and others must be sought to assist in reviewing and improving the quality of care provided to service users. The home’s staff supervision procedures need to be improved to ensure that staff, remain effective in addressing service users’ needs. The home needs to improve health and safety arrangements in identified areas to ensure that service users and others working at the home and visiting are fully protected. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 20 EVIDENCE: The supervision files were inspected and the manager’s supervision notes had not been signed or dated. The most recent supervision notes were not available for inspection. Insufficient staff supervision is being provided to staff in the home, which means that a professional, consistent approach cannot be maintained. A requirement has been restated accordingly. The assistant managers undertake some supervision of staff and keep the supervision records in their personal lockers. This supervision process is also insufficient to ensure staff, are fully supported to meet the needs of service users. The manager of the home does not have access to these supervision records, to undertake monitoring of staff supervision to ensure it is effective. A requirement has been restated accordingly. The manager must ensure that a new quality assurance audit is undertaken as the most recent quality assurance audit took place on the 04/08/05 and mainly consisted of questionnaires to service users and health and safety checks. This process will provide feedback to the home in relation to the quality of care provided to service users living in the home and service users’ views in order to improve the quality of care provided. A requirement has been made in relation to this. The records of fire alarm checks and fire drills were inspected and found to be in order. Fire equipment was inspected and found to be up to date. The electrical certificate was found to be in order, which ensures that the health and safety of service users living in the home is improved in these areas. Hibiscrub is provided in a number of bedrooms and bathrooms in the home and is not stored appropriately, to ensure that the health, safety and well being of service users are maintained. Hibiscrub must be stored appropriately to ensure service users are not at risk. A requirement has been made in relation to this. The inspectors observed, looking through the accidents book, that a number of accidents recorded involved admissions to hospital due to fractures or other concerns but these had not been reported to the Commission as required under regulation 37 notifications, to ensure clear monitoring and recording of accidents in relation to service users. A requirement has been made in relation to this. The inspectors noted that COSHH cleaning materials had been left unsupervised in the first floor bathroom which does not minimise the risk of harm from these substances to service users. A requirement has been made in relation to this. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 21 The current manager is leaving on 30/06/06 and during a discussion with the responsible individual at the end of the inspection, a requirement was made that the home write to the Commission advising of the arrangements to be regarding the management of the home during the period that the home does not have a manager, to ensure that the home is managed effectively and service users’ needs are met. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 22 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 X X 3 X X X HEALTH AND PERSONAL CARE Standard No Score 7 2 8 2 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 2 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 2 17 X 18 3 3 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 3 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 X 2 X X 1 1 2 Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 23 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 Requirement The registered provider must ensure that service users care plans contain clear goals and are updated on a monthly basis. The registered provider must ensure that service users are supported to have an annual care plan review meeting with their care manager. Restated from the previous inspection. Timescale not met 01/03/06. The registered provider must ensure that risk assessments are completed for all of those service users who use bedsides and any other ways that minimise service users falling from their beds. The registered provider must ensure that risk assessments are regularly reviewed and kept up to date. The registered provider must ensure that the identified service user who suffers from oedema in their feet has a risk assessment completed to minimise the identified risk to the service user. The registered provider must DS0000010421.V292035.R01.S.doc Timescale for action 10/08/06 2. OP7 15 01/09/06 3. OP38 13(4) 14 28/07/06 4. OP38 13(4) 14 13(4) 14 01/08/06 5. OP38 28/08/06 6. OP38 13(4,5) 20/07/06 Page 24 Church Walk House Version 5.1 14 7. OP9 8. OP9 9. OP9 10. OP16 11. OP19 12. OP30 13. OP29 14. OP36 ensure that the identified service user who has a manual handling assessment must identify how many staff are needed to meet the service user’s needs. 13(2) The registered provider must ensure that medication is clearly recorded on the medication administration record at the time of administration. 13(2) The registered provider must ensure that medication is ordered well in advance to ensure that supplies do not run out for service users. 13(2) The registered provider must ensure that procedures are put in place to identify that if a service user is running short of an identified medicine, that this medication can be obtained without delay. 22 The registered provider must ensure that all complaints are identified in the complaints book and if information is filled separately this is noted in the complaints book. 23 The registered provider must (4)(III) ensure that fire safety notices contain all relevant information to ensure service users and staff know what action to take in the event of fire. 18(1ci) The registered provider must ensure that staff have an individual training record including copies of their training certificates. Restated from the two previous inspections. Timescale not met 15/02/06. 19 Sched2 The registered provider must ensure that the identified staff member obtains an up to date CRB. Immediate Requirement. 18 (2) The registered provider must ensure that staff receive regular individual supervision at least DS0000010421.V292035.R01.S.doc 15/07/06 15/07/06 18/07/06 16/07/06 17/07/06 20/08/06 19/06/06 27/07/06 Page 25 Church Walk House Version 5.1 15. OP36 18(2) 16. OP33 24 17. OP38 13 (4)(a) 18. OP37 37 19. OP38 13(4) 20. OP31 8 every two months. Restated from the previous inspection. Timescale not met 20/01/06 The registered provider must ensure the supervision records are stored so they can be accessed by the manager as required. Restated from the previous inspection. Timescale not met 10/12/05. The registered provider must ensure a new quality assurance audit is undertaken involving service users relatives and other professionals. The registered provider must ensure Hibiscrub is stored appropriately to ensure service users are not at risk. The registered provider must ensure that all serious incidents including accidents are reported to the Commission under regulation 37. The registered provider must ensure that all COSHH materials are stored appropriately to ensure there is no risk of harm to service users. The registered provider must ensure that they write to the Commission informing them of the arrangements to be made in relation to who will manage the home for the period the home does not have a manager. 20/07/06 02/09/06 15/07/06 15/07/06 15/07/06 15/07/06 Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 26 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. 3. Refer to Standard OP8 OP8 OP12 Good Practice Recommendations A copy of the medication prescription should be attached to the MAR sheet. The general practitioner should be consulted regarding medication which is only given when the service users wish to see if these medications can be prescribed as PRN. The activities organiser should undertake the Midas training so she can drive the hired minibuses. Church Walk House DS0000010421.V292035.R01.S.doc Version 5.1 Page 27 Commission for Social Care Inspection Southgate Area Office 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 © This report is copyright Commission for Social Care Inspection (CSCI) and may only be used in its entirety. 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