Inspection on 04/07/08 for Church Walk House

This inspection was carried out on 4th July 2008.

CSCI found this care home to be providing an Good service.

The inspector made no statutory requirements on the home as a result of this inspection and there were no outstanding actions from the previous inspection report.

Other inspections for this house

Church Walk House 07/04/09

Church Walk House 29/05/07

Church Walk House 16/06/06

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 27/09/2008.

CARE HOMES FOR OLDER PEOPLE Church Walk House Church Walk Childs Hill London NW2 2TJ Lead Inspector Duncan Paterson Key Unannounced Inspection 09:30 4th & 15th July 2008 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.V366591.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 Walk House DS0000010421.V366591.R01.S.doc Version 5.2 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 wayne@churchwalkhouse.org Hendon Old Peoples Housing Society Wayne Harry Hughes Care Home 42 Category(ies) of Dementia (0), Old age, not falling within any registration, with number other category (0) of places Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: 1. The Registered Person may provide the following category of service only: Care home only - Code PC to service users of the following gender: Either whose primary care needs on admission to the home are within the following categories: Old Age, not falling within any other category - Code OP 2. Dementia - Code DE The maximum number of service users who can be accommodated is: 42 4 February 2008 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, smaller 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 double 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, senior staff and a team of carers. There is also a team of ancillary staff including cleaners, cooks and laundry assistants. The fees are between £470 to £550 per week. The inspection report and other documentation about the service are available on display within the entrance hall of the home. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The quality rating for this service is 2 star. This means the people who use this service experience good quality outcomes. This key inspection took place on 4th and 15th July 2008. The inspection involved time at the home talking with residents, staff, relatives, visiting professionals and the manager. A standard form, the Annual Quality Assurance Assessment (AQAA), was returned to CSCI by the manager. This was taken into consideration. Five resident’s care files were inspected. The inspection also involved the assessment of a range of the home’s records, procedures and forms as well as observation and a tour of the premises. A CSCI Pharmacy inspector inspected the medication arrangements. Surveys were returned from residents and staff and the home’s quality assurance report for May 2008 was used. This involved feedback from 17 residents and advocates. What the service does well: The manager and staff have created a pleasant, friendly atmosphere which residents like and value. One resident for example, said that she loved the home and found staff, “very helpful and caring”. A staff member described the home as having, “a good atmosphere for residents”. The activities provided are good. There is an energetic and experienced activities co-ordinator. Again, positive comments were received about this. One resident in a returned survey said, “the activities are excellent”. The food provided is highly regarded by both residents and staff. Meal arrangements are well organised with mealtimes an enjoyable experience for residents. One resident described the food as, “always excellent”. Complaints are responded to in a thorough and sensitive manner and there has been action to correct matters when complaints were substantiated. There is also some good management practice in terms of maintaining a safe environment. Maintenance and fire checks for example are well presented and recorded. The quality assurance work is good with detailed reporting and analysis of what people say about the service. Staff have received a range of relevant training. Being provided with training was seen as a positive aspect by staff and many positive comments were received about this. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 6 What has improved since the last inspection? What they could do better: The improvements noted above need to be continued. For example, some specific work in relation to medication is required and this is outlined in the requirements section of the report. There were some adverse comments from staff and some residents about the home’s physical standards. Particularly some confined areas, such as the small lounge, which made it difficult for people with mobility difficulties. There is to be an occupational therapy assessment of the home and this should assist with identifying how matters can be improved. The staff recruitment process has improved but can be improved further by making sure that work histories are detailed, that checks of references are recorded and that references match staff application details. A relatives meeting need to be arranged. This was something that we had asked the manager and management committee to arrange at a meeting we had with them in March 2008. These meetings are important as they provide the opportunity for the service to communicate with relatives, detail what has happened at the home and what the plans are for the future. There is a need to review the secure storage spaces available for residents in order to provide residents with a secure place to keep valuables if desired. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 7 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 Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 8 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.V366591.R01.S.doc Version 5.2 Page 9 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): 13&4 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Improvements have been made to the information available about the service. There are now detailed documents available. There is a competent assessment process with relevant details either compiled by or obtained by the service. Consideration has been given to addressing service provision equality and diversity matters. EVIDENCE: There is a relatively new statement of purpose (dated 2007), a copy of which was provided. This is a detailed document setting out a whole range of matters including details about the staff and their training as well as the complaints procedure, care and activities arrangements. This is no specific section setting out the aims and objectives of the service and it is recommended that such a section be added. This will make it clearer to prospective residents and others what the service is setting out to achieve. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 10 The CSCI case tracking methodology was used to assess the care arrangements. This involves selecting a sample of residents and looking in detail at the care arrangements including the care plan and assessment information. Five individual care plans and assessments were inspected and where possible the residents and relevant staff (such as keyworkers) were spoken with. The majority of these residents had been living at the home for a long time. There have been few recent admissions of residents. Background details are complied about new residents including details of their needs. Internal admission information for each resident is drawn up which is complemented by information provided by local authorities. The majority of residents have had their placements arranged through local authorities. Eight residents were spoken with. Overall, a positive response was received with many residents making favourable comments. Residents like the home and the atmosphere. For example, staff were praised and described as, “very helpful”. One resident said that, “this is a very friendly place”. Where residents had concerns or questions these were raised with the manager. Two relatives and friends were spoken with during the inspection. They both said that they visited often. One said, “they make me welcome when I visit”. The other said that staff were, “caring and nice”. The AQAA returned set out work that had been carried out in relation to equality and diversity. This included the promotion of equal opportunities in the provision of the service, maintaining records, having a diverse spectrum of staff and residents as well as being able to cater for different religious and dietary needs. This inspection has identified that there is a diverse staff team and that they are able to respond to difference within the group of residents. For example, the manager and activities co-ordinator had lead some recent work to make sure that care planning documentation became more person centred in recording work had carried out with residents. There was a recommendation given at the last key inspection about providing an equal opportunities statement in the service users’ guide. This is still needed and the recommendation has been repeated. The manager described in the AQAA document that this work had been delayed until equality and diversity training had been provided in the summer. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 11 Health and Personal Care The intended outcomes for Standards 7 – 11 are: 7. 8. 9. 10. 11. The service user’s health, personal and social care needs are set out in an individual plan of care. Service users’ health care needs are fully met. Service users, where appropriate, are responsible for their own medication, and are protected by the home’s policies and procedures for dealing with medicines. Service users feel they are treated with respect and their right to privacy is upheld. Service users are assured that at the time of their death, staff will treat them and their family with care, sensitivity and respect. The Commission considers Standards 7, 8, 9 and 10 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 7 8 9 & 10 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There are good links with health care professionals and there have been improvements to the handling and recording of medication. This has lead to benefits for residents. The care planning system, although adequate at present, is to be developed and this should provide an improved service for residents as well as make it easier to use for staff. EVIDENCE: As described above, five resident’s individual case files were inspected as part of the case tracking methodology. The residents needs vary and included people who have dementia care needs as well as those with input from health care professionals. Overall, the care plans and records of care were satisfactory. The required information was available and had been kept up-todate. There was evidence of regular reviews. There were additional risk assessments and profiles covering, for example, manual handling risk assessments as well as pressure area assessments. Care plans had also been updated since the last key inspection to include details about activities as well Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 12 as to make them more user friendly with easier to follow data. The activities co-ordinator had taken the lead for this work. However, the care planning system used (the Standex system) was considered by the manager and some of the staff spoken with, to be somewhat cumbersome and difficult to use. The manager plans to introduce an easier to use care planning system. This will be a major piece of work but once introduced, the system should bring benefits for staff and residents alike. The care plans included details about involvement from health care professionals including the district nursing service as well as records of GP and other health related appointments for residents. The district nurses keep their own records of care but there were internal records which complement those. One person had a pressure ulcer which was being treated by a district nurse and staff had been provided with guidance and equipment. The district nurse manager was spoken with on the telephone. She said that staff were always helpful, that there was good communication, that staff at the home worked well with the district nurses and that there was a focus on dignity with residents. We inspected the records of receipts, administration and disposal of medication in the home and audited the stocks of medication against the records. All the MAR (medication administration records) were inspected and it was pleasing to note that these were generally completed accurately. Stock left in the blister packs could be tracked to endorsements for refusal or when the resident was in hospital. All the tablets in the original packs sampled could be accounted for. The occasional omissions in administration were noted for some creams, and alendronate the morning of the inspection because the MAR could not be located. No medicines were recorded as out of stock and the MAR could be easily checked against the copies of the original prescriptions for evidence of the current medication. Hospital discharge letters were tracked and it was suggested that copies of these too be kept with the MAR for reconciliation of medication on return from hospital. This would help to prevent error and add to the checking procedures put in place following the recent omission of a heart medicine on a hospital discharge letter. There was evidence of review of medication including pain relief by the GP .The GP signed the MAR when adjusting doses of medication and the changes could be tracked to records in the care plans. The history of allergy was not always recorded on the MAR. If there is no allergy then no allergy known should be recorded. The clinical room was tidy, clean and well organised and the temperature was monitored daily and was within the required range. Controlled drug (CD) Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 13 balances were inspected and were correct. Recording in the register though was untidy with spaces left between lines, crossings out and no witness signatures for the disposal of some CD. There was concern expressed at the potential risk of accidental ingestion of potassium permanganate tablets prescribed for external soaking of a sore limb. The home was advised to store these with external products rather than with the oral medication. Dates of opening were written on liquid medicines and new packs of medicines opened. It was noticed that this practice was not always extended to eye drops, which have a short shelf life when opened. The home had received medication training from the supplying pharmacist who also carried out regular audits. The manager was randomly carrying out audits but not always every month and these were inspected. The manager had identified a measuring issue with liquids for one of the residents and had taken appropriate action in improving measuring technique. During the premises tour two tablets were found on an external first floor window sill. It was not possible to accurately identify what the medication was or how it had got onto the window sill. Most likely they had been discarded by a resident. This was discussed with the manager. There is a need to ensure that staff are vigilant when administering medication and are able to address any incidents of refusal. Church Walk House DS0000010421.V366591.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 15 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Activity provision and the quality of food provided are two strengths of this service. There is a varied programme of activities delivered by experienced staff as well as plans for further improvement. There is a need for all care staff to engage with residents particularly those residents with dementia. Meal provision is good with residents enjoying good food in pleasant surroundings. EVIDENCE: Church Walk House has an activities co-ordinator who has many years experience at the home. The co-ordinator is very knowledgeable about the home and the residents and is committed to her work. Time was spent during the inspection discussing her work and the activities provided. There is good presentation of activities with colourful posters on display in the home. There are also daily activities with the activities co-ordinator taking the lead for these. She is supported by a volunteer who also provides activities one day per week. There are other volunteers as well as supportive relatives. Activity sessions were observed during the inspection such as a quiz in the main lounge and one-to-one work with residents in the dining room. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 15 Residents praised the activities co-ordinator and the activities provided. One resident told us that, “there was a lot going on”. Relatives were also positive about the activities but reported that they wished more stimulation for residents as well as regular meetings. The returned AQAA set out additional work that is carried out such as music and drama therapy sessions and the organisation of large events for friends and supporters such as the summer garden party and Christmas party. The home’s quality assurance report identified that there was great satisfaction with social stimulation. 35 of people responding were very happy and 47 were happy. The AQAA stated that there are plans to improve activity provision in the future. These initiatives include: more external activity such as trips out; raising funds to buy an adapted minibus; installing a wooden gazebo to encourage more use of the garden, and; encouraging staff to improve the daily one-to-one activities for residents. This last point is particularly important as residents at the home, especially those with dementia, will need to be stimulated when the opportunity arises. This may not be at times when the activities co-ordinator is present. Further, positive encouragement from staff and others has been seen to be beneficial to the quality of life for people with dementia. Staff were seen to engage positively with residents. However, there were times during the inspection when staff were seen to be passively sitting in the lounge alongside residents but not engaged with them in any activity or interaction. A recommendation is given about this. Progress with organising a relatives meeting was discussed with the manager. We had earlier asked the management committee to arrange such a meeting as part of a package of measures to improve the overall service. A relatives meeting had not yet taken place. The last relatives meeting was in November 2007. It is important that such a meeting takes place and a recommendation is given about this. Food provision is considered very good by many at the home, residents as well as staff. The kitchen and food handling arrangements have been inspected by Barnet Council’s Environmental Health department and 5 stars have been awarded. (5 stars is the maximum possible). Many of the residents praised the food. The serving of lunch on the first day of the inspection was observed. The majority of residents eat in the dining room at small tables seating three to four people each. The dining room is spacious and has lots of windows. It is a pleasant place to eat and staff served residents carefully making the meal an enjoyable experience. The small lounge is also used for meal provision where staff can assist residents with higher needs to eat. There is a higher ratio of staff here with some residents receiving one-to-one assistance. Staff were observed to be working sensitively with residents. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 16 Staff were spoken with and demonstrated a good knowledge of residents’ dietary requirements. There are a number of diabetics for example as well as some residents who require a softer diet. The home’s quality assurance report reported that 65 of people were very happy with the quality of meals and that 29 were happy. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 17 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be. JUDGEMENT – we looked at outcomes for the following standard(s): 16 & 18 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. The complaints procedure is clear and complaints made have been investigated and responded to in an open and positive manner. Safeguarding arrangements are suitable with training now extended to all staff. EVIDENCE: The complaints policy is on display in the entrance hall as well as detailed in the statement of purpose. The complaints records show that there have been 11 complaints made in the last year. The responses to complaints are thorough and clearly document the complaint, how investigated and the response. There were letters to the complainant detailing what action had been taken. The letters were open and informative and included an apology or further details if required. There was a good standard of complaint response from the service. Some of the complaints highlighted problems with the service on which the manager had been able to take action to address. For example, there had been complaints about the laundry and the manager had been able to appoint a new laundry assistant. The safeguarding arrangements involve training for staff as well as a revised safeguarding policy and procedure. Many of the staff have received safeguarding training and a further training course had been arranged for the week following the inspection. The safeguarding policy is clear but needs to be amended slightly so that it is clear that the lead authority for responding to safeguarding matters is the local authority. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 18 The manager is clear about the responsibility for reporting incidents or allegations of abuse to the local authority and to us. Since the last key inspection there has been a safeguarding incident and a meeting hosted by the local authority. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 19 Environment The intended outcomes for Standards 19 – 26 are: 19. 20. 21. 22. 23. 24. 25. 26. Service users live in a safe, well-maintained environment. Service users have access to safe and comfortable indoor and outdoor communal facilities. Service users have sufficient and suitable lavatories and washing facilities. Service users have the specialist equipment they require to maximise their independence. Service users’ own rooms suit their needs. Service users live in safe, comfortable bedrooms with their own possessions around them. Service users live in safe, comfortable surroundings. The home is clean, pleasant and hygienic. The Commission considers Standards 19 and 26 the key standards to be inspected. JUDGEMENT – we looked at outcomes for the following standard(s): 19 20 21 22 23 24 25 & 26 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Although the home is not modern an attractive and welcoming environment for residents has been created which is gradually being improved. A forthcoming occupational therapy assessment will assist in improving the environment, particularly for people with mobility difficulties, who currently experience some difficulty in parts of the home. EVIDENCE: The care home is made up of the original vicarage building and a 1950s extension, which includes a two storey wing which has the majority of the bedrooms. There is an additional building which houses a sheltered housing service. This is not part of the registered care home. There are a number of attractive features and parts of the home where the original character has been retained. The communal areas, for example, have high ceilings and large windows allowing lots of light. There is also a very Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 20 large attractive garden which has been well maintained and provides a tranquil space for residents. Internally, there have been improvements. For example, some of the bedrooms, which had been used as double bedrooms in the past, have been converted into single bedrooms with en suite facilities. Work is continuing to complete this change. The home is not new and therefore was not built or designed to meet contemporary standards. For example, there are some parts of the home where space is limited, such as the small lounge. The shaft lift is comparatively small and the kitchen and laundry room are accessed via steep stairs. Some of the staff commented that using the mobile hoists in parts of the home was difficult. This caused some problems with supporting residents. It was also clear talking to residents that there were times when use of the hoist was not an enjoyable experience. A senior care worker said that he took the lead for use of equipment such as hoists and that he was able to train and advise staff on safe use. The manager advised that an occupational therapist had been engaged to carry out an assessment of the building as to the suitability of caring for people with physical disabilities. This will be useful and may lead to environmental improvements for residents. The premises were inspected with the manager. There is a bathroom and shower room on the ground floor as well as the first floor. A small number of bedrooms have en suite facilities. The bedrooms seen were comfortable and had been personalised. The new bedrooms were inviting and attractively presented and the variety of style within the home made for a pleasant environment. There are three ground floor communal rooms. A main lounge, a smaller lounge and a large dining room. The manager said that consideration was being given as to how to best use these rooms. Currently, the majority of the residents use the main lounge for most of the day. The dining area is therefore quieter. A small number of matters were identified during the premises tour which will need to be addressed. The bath lifting mechanism in the ground floor bathroom is not working and needs replacement. There were some broken tiles at floor level in the ground floor shower room and these need repair. There was a cracked pane of glass in the large ground floor lounge. And there were a number of call bells in bedrooms which did not have leads. This needs review so that residents can have access to the call bell system when required. The laundry is in the basement in the old vicarage part of the home. Space is fairly limited. However, there is space for two washing machines and a dryer as well as separate space for ironing and temporary storage of clothes before Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 21 being given back to residents. One of the washing machines had developed a fault and a replacement part had been ordered. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 22 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 & 30 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. There has been an improvement to staff relations with a consequent beneficial effect on the service for residents. Further work is needed and the manager has plans in place to make these improvements. Recruitment needs to be more robust so that potential risks to residents are minimised. Staffing numbers need to be regularly reviewed with additional staff made available when needed. EVIDENCE: The last key inspection identified that staff relations were poor and were having a negative impact on the quality of service received by residents. Subsequent safeguarding concerns provided further evidence of the need to improve staff relations and introduce more effective management. This inspection has identified that there has been improvements at the home and that the manager and management committee have been successful in addressing the concerns and improving the service. This work is not yet complete but the manager was able to describe further work that was planned to continue with the improvements. Staff and relatives spoken with said that things had improved at the home. Staff said that the staff team now got on with each other much better. The recent staff team building sessions were described as, “useful” and that the Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 23 atmosphere at the home was, “much better”. However, there were still some concerns raised by staff. These were discussed with the manager. Some may have been historical, such as the feeling of unfairness experienced by some staff as to how matters had been addressed by the management committee. However, the manager has plans to address problems and felt that increased staff supervision had helped to improve matters. The staffing rota was seen. Normally, there are seven members of staff working in the morning, five in the afternoon and three at night. This was the case on the two days of the inspection. Staff spoken to said that one of the challenges they faced was that of providing care when the staffing levels were low. Staff said this happened on occasion. This was discussed with the manager who advised that higher numbers of staff than were needed were scheduled to work to address this type of issue. The manager also said that sickness levels were high and this was in part a cause of problems such as staff calling in sick at short notice and there being difficulties in providing cover. The manager advised that this was being addressed and was able to show some documentation about this as evidence. In addition, new staff had been recruited which should further alleviate problems. It is clearly important that staffing levels are kept under review to ensure that there are adequate numbers of staff for the needs of residents. The number of residents living at the home was 32 which is fewer than the registered numbers of 42. Should the numbers increase then more staff on duty will be required. The deputy manager had recently left the home. The manager said that there were plans to amend the staff structure so that there were three staff teams within the home. Each team to have their own team leader. Should this be successful it will assist in addressing staff shortage problems and improve the service for residents. Five staff files for the newer members of staff were inspected to check the recruitment arrangements. Four further staff files were inspected to check staff training. Overall, staff recruitment was being carried out properly. However, there were some matters that need to be addressed to ensure that recruitment is as robust as possible. For example, there were references from employers which were not specified by staff on their work histories. Some references were given and accompanied by headed paper. However, the person providing the reference was not the manager of the organisation. On one staff’s application form there were no records of having telephoned checked the references although the manager said that they had been checked. Work histories and references need to be linked and checked with records kept. The failure to do this means that it is not possible to confirm that staff have been recruited properly and residents may be at risk. A requirement is given about this. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 24 The manager reported that he had reviewed all staff files and found some problems such as there not being evidence of identification for 12 staff. This is historical with checks most likely not having been kept at the time of recruitment. The manager undertook to obtain copies of identification for all staff. The staff files provided evidence that that there had been an investment in staff training. The records showed that staff had received training including in the areas of food hygiene, first aid, fire safety, dementia, medication, safeguarding adults and NVQ training. Staff spoken with confirmed that they had received the training. Many staff members saw the provision of training as one of the positive aspects of working at the home. The AQAA stated that 14 out of the total of 20 care staff had obtained NVQ qualifications at either level 2 or above. Again, staff spoke with confirmed that they had completed these qualifications. Staff confirmed that there were staff meetings. Written records of these meetings were seen. Although the average number of staff attending was 10 the records were detailed and provided evidence of a range of relevant matters discussed. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 25 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 32 33 35 36 37 & 38 People who use this service experience good outcomes in this area. This judgement has been made using available evidence including a visit to this service. Residents have benefited from management changes. The manager now receives regular supervision from an external professional supervisor. The manager and management committee have been able to set up effective communication and decision making channels. Quality assurance initiatives are good, staff supervision is competently provided and there is a thorough approach to health and safety. EVIDENCE: The manger has now been at the home for 18 months. This has been a period of great change as well as one of some turbulence. There have been staffing problems to address as well as a safeguarding matter which highlighted problems with medication management and management in general. This key inspection has identified that some of the management changes and new Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 26 initiatives have borne fruit with improvements for residents and staff. A number of positive comments were made about the manager by staff. The manager identified that the new supervision arrangements for him (provided from an external professional supervisor) had been very helpful and provided a valuable source of help and support. Weekly meetings with the management committee are taking place and these assist with the tackling of arising issues as well as communication. The manager has a lot of plans for the future and now seems to have the support and backing to put these plans into operation. The plans have been detailed in the report and include matters such as staff deployment and care planning. If successful there will be improvements for the quality of care provided at the home. An example of a successful piece of work by the manager has been the recent quality assurance work. The manager described the work that had been done and presented a copy of the May 2008 quality assurance report. The report is detailed and presents a great deal of background information about how the service is performing based on what people have said and compared to last year. Relatives and advocates of the service were asked to respond to specific questions in a range of areas including dignity, food provision, care planning and activities. The findings are detailed in the report. The arrangements for looking after residents’ money were inspected. Money is looked after for seven residents where there are no other relatives or advocates. Benefits are paid into a residents account with money in this account used to pay for day-to-day items such as toiletries and hairdressing. For other residents such costs are reimbursed by families or other persons (advocates or legal people) who may be in charge of resident’s financial affairs. A potential problem was identified concerning the safekeeping of residents money within their own bedrooms. There was uncertainty as to which residents wished to, or were able to, look after their own money and whether there were lockable facilities in bedrooms to do this. The manager undertook to review this and provide lockable facilities where required. Staff supervision records were inspected when looking at the sample of nine staff files. There were records of regular supervision on staff files and staff confirmed that they were receiving supervision. The home’s maintenance, fire safety and safety checks were inspected. These provided evidence that a thorough approach was taken to health and safety and maintaining a safe environment. Regular checks had been completed with equipment checked and certificated by external professionals where needed. Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 27 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Older People have been met and uses the following scale. The scale ranges from: 4 Standard Exceeded 2 Standard Almost Met (Commendable) (Minor Shortfalls) 3 Standard Met 1 Standard Not Met (No Shortfalls) (Major Shortfalls) “X” in the standard met box denotes standard not assessed on this occasion “N/A” in the standard met box denotes standard not applicable CHOICE OF HOME Standard No Score 1 2 3 4 5 6 ENVIRONMENT Standard No Score 19 20 21 22 23 24 25 26 3 X 3 3 X N/A HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 2 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 X 18 2 2 3 3 3 3 3 3 3 STAFFING Standard No Score 27 3 28 4 29 2 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 3 3 4 X 3 3 3 3 Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 28 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 Standard OP9 Regulation 13(2) Requirement That controlled drug recording in the register is improved so that there are no crossings out, no spaces between lines and witness signatures are always obtained if controlled drugs are received, administered or disposed of. That the history of allergy is written on all MAR charts. If there is no allergy then no allergy known must be written. Ensure that the safeguarding policy and procedure makes clear that the lead authority for responding to safeguarding incidents and allegations is the local authority. Carry out repairs to the following: • the ground floor bathroom bath lifting mechanism • the broken tiles in the ground floor shower room • the cracked pane of glass in large lounge. Review all call bells in residents’ bedrooms providing a lead where required. DS0000010421.V366591.R01.S.doc Timescale for action 15/08/08 2 OP9 13(2) 15/08/08 3 OP18 13(6) 01/10/08 4 OP19 23(2)(b) 01/10/08 5 OP19 23(2)(b) 01/09/08 Church Walk House Version 5.2 Page 29 6 OP29 19 (1)(b)(i) Sch 2 19 (1)(b)(i) Sch 2 7 OP29 Ensure that all applicants for work provide full work histories and that references obtained match the work histories. Ensure that copies of identification are obtained for all staff. 01/09/08 01/10/08 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 The service user guide should contain a suitable and encompassing equal opportunities statement about how the home welcomes people from different backgrounds and cultures. The statement of purpose should have a specific section detailing the aims and objectives for the service. That all care staff should provide activities for residents taking opportunities throughout the day when residents are receptive for one-to-one work. Regular relatives meetings should take place. There should be a review of lockable facilities in residents’ bedrooms providing such facilities where needed. 2 3 4 5 OP1 OP12 OP13 OP24 Church Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 30 Commission for Social Care Inspection London Regional Office 4th Floor Caledonia House 223 Pentonville Road London N1 9NG 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 Walk House DS0000010421.V366591.R01.S.doc Version 5.2 Page 31 - 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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