Inspection on 08/12/05 for Church Walk House

This inspection was carried out on 8th December 2005.

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 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 04/07/08

Church Walk House 29/05/07

Church Walk House 16/06/06

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 Unannounced Inspection 8th December 2005 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.V265256.R01.S.doc Version 5.0 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.V265256.R01.S.doc Version 5.0 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.V265256.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. Two specific service 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. Limited to 42 service users who are elderly and may have dementia. 2. Date of last inspection 11th April 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 DS0000010421.V265256.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This was an unannounced inspection conducted by two inspectors. The inspection took place over approximately five hours. A tour of the premises took place. The staff records and care records were inspected and the inspectors met with residents and staff and also one relative. What the service does well: What has improved since the last inspection? What they could do better: The medication must be recorded appropriately on the MAR sheets and medication must be stored below 25°C to prevent the deterioration of medicines. A requirement has been made in relation to these. The fire safety notices must contain all necessary information. A requirement has been made in relation to this. One fire exit had been blocked to prevent the easy access of a resident. All fire exits must be clear. A requirement had been made in relation to this. All necessary recruitment records must be in place. An immediate requirement has been made in relation to this. There needs to be a Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 6 clear training record to show the training that staff have received. A requirement had been made in relation to this, restated from the previous inspection. All staff must have regular supervision. A requirement has been made in relation to this, restated from the previous inspection. Staff supervision notes must be available at all times to the manager of the home. A requirement made at the previous inspection, restated at this inspection. The quality assurance system must be implemented and feedback compiled into a report and sent to the local CSCI area office. A requirement made at the previous inspection, restated at this inspection. 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.V265256.R01.S.doc Version 5.0 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.V265256.R01.S.doc Version 5.0 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, 4, 5 The admissions process is working well. Residents are assessed and 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 file notes of three residents were inspected and contained appropriate assessments completed by care professionals. These assessments confirmed that the care needs of these residents could be appropriately met by the home. One resident who was newly admitted to the home spoke with the inspector during the inspection. She had been invited to visit the home with her family before she moved in and it did not appear that she was having difficulty adjusting to these new arrangements. The inspector observed staff providing adequate support and encouragement to the residents living in the home. Families can visit their family members and have the opportunity to have free access to the management staff when required. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 9 During the inspection the inspector noted that staff seemed very knowledgeable in relation to the residents’ individual needs and all residents spoken with confirmed they were happy with the care provided. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 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 the following standard(s): 7, 8, 9, 10 This standard has been partly met. Care plans have been updated, however, one resident has not had a care plan review meeting with their manager. The standard way in which information is recorded on care plans does not always clearly identify that all needs are met. EVIDENCE: The case notes for six residents who live in Church Walk were inspected. The care plans contained clear goals and had been updated on a monthly basis. A requirement made at the previous inspection. Some residents have had a care plan review meeting with their care manager in the last year. However, one resident has not. A requirement has been made in relation to this. The residents had been seen by the chiropodist, optician, dentist and GP. However, this was not always clearly recorded. A good practice recommendation has been made in relation to this. Residents had records of appointments and input from specialists and risk assessments were up to date. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 11 It was observed by both inspectors that a number of residents move around the home with the use of a wheelchair. A number of wheelchairs were being used without foot rests in place. A requirement has been made in relation to this. Restated from the previous inspection. The wheelchairs were clean, this was a requirement made at the previous inspection. One resident refuses to use footplates and the resident spoke with the inspector and his care plan was seen. It must have this information recorded within it. A requirement has been made in relation to this. The home uses the Boots Medication Administration System. The controlled drugs register was examined. It was noted that the number of larazepam tablets for a resident, which was recorded in the register as the balance remaining, did not tally with the actual amount in the container. It was not clear what the prescribed dose should be. The staff said that the GP had recently increased the dosage from 10mg to 20mg, but it was not properly recorded in the MAR sheet, and the prescription was not available for inspection. A requirement has been made in relation to this. It is good practice for a copy of the prescriptions to be attached to the MAR sheets for clarification. The records of the temperature of the room containing medication showed that this often exceeded 25°C. it is a requirement that medication is stored below 25°C to prevent deterioration of the medicines. A requirement is made in relation to this. The residents spoken with were all very happy with the care provided. All of the residents’ appearance was of a high standard. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 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 The residents experience a range of excellent activities that meet their individual needs. The food is excellent and presented in an attractive manner. This standard is exceeded. EVIDENCE: The activity programme was seen and offers a range of activities throughout the day. Some activities were taking place on the day of the inspection and the inspector spoke with the facilitator concerned. Some activities are led by staff employed by the home, others by external professionals. The activities witnessed were in relation to Christmas and discussing what residents used to do e.g. making Christmas puddings and what they used to put in them. The residents obviously enjoyed this and the session was carried out in a very person centred enthusiastic way. This assists residents to maintain their skills. The manager had a carrier bag full of thank you cards. A good practice recommendation has been made in relation to this. The food seen in the home was fresh produce. It was of good appearance, nutritious and wholesome. The presentation of the food was excellent with fresh fruit and vegetables available. The cook showed the inspector his list of residents likes and dislikes and their personal choices were identified. The kitchen was clean, tidy and well organised. The cook makes cakes/Christmas Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 13 puddings for the residents, which they then present to their relatives as a gift for Christmas. This is a very personal touch when they are unable to shop for items themselves. The residents have the use of two dining rooms, one of these rooms is smaller and more appropriate for those residents who need more assistance. The residents spoke with the inspector and expressed their satisfaction with the food available. The inspector ate a meal with the residents and was impressed with the standard of food and its presentation. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 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): 18 The home has the necessary procedures in place to protect residents from abuse. EVIDENCE: Staff training has taken place in relation to adult protection and the planned training mentioned in the previous report has taken place. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 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 Church Walk is an old building with a rather institutional layout but despite these limitations it offers a homely, comfortable environment. However, improvements need to be made to ensure the residents live in a safe environment. EVIDENCE: The home is clean, tidy and attractive. The home has adequate facilities in terms of the communal space provided. There are adequate bathrooms, showers and toilets, which are accessible to those with disabilities. Church Walk was immaculately clean throughout, is fully adapted, including internal rails, ramps, lift and call system. The residents’ bedrooms are clean and tidy. The rooms are lockable and there is an adequate area for safe storage of valuables. The laundry is well equipped with adequate machinery. Laundry is labelled and placed in individual baskets to ensure it is returned to the correct person. The member of staff employed to complete this task and also iron the clothes spoke with both inspectors and was happy working at the home. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 16 The fire safety notices must contain all relevant information. A requirement is made in relation to this. At the time of the inspection one fire exit was blocked by a wheelchair, the explanation given by a staff member was that the resident has a history of attempting to leave the building. Fire exits must be clear at all times. A requirement has been made in relation to this. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 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 The standards are partly met. The home has a reasonably stable staff team. However, the manager must ensure that all necessary recruitment information is available and in place. Also, clear training records have to be available to ensure the safety of residents and their individual needs are met. EVIDENCE: Staff files were inspected and not all staff had the necessary criminal records bureau checks or protection of vulnerable adults confirmation. All staff did not have a copy of their passport available and there was not always evidence of authorisation to work in the country for the period in which they were employed. An immediate requirement was made in relation to this. There needs to be a clear record of training to show the training that staff have received and when this has taken place. A requirement has been made in relation to this, restated from the previous inspection. A member of staff had completed their NVQ level 2 and 3. Staff have received fire safety training dated 1/12/05, food hygiene training dated 29/9/05, medication training dated 5/2/05 and staff have completed a four day course in basic first aid. All of the above were requirements made at the previous inspection. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 18 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, 32, 33, 36, 38 These standards are partly met. The manager must ensure that systems for reviewing the performance of the home are fully in place. All staff must be regularly supervised and this record must be available for inspection at all times within the home to ensure standards are met for both staff and residents. EVIDENCE: The staff supervision records were inspected. All staff have not received regular supervision. A requirement has been made in relation to this, restated from the previous inspection. All staff must have an annual appraisal. A requirement has been made in relation to this, restated from the previous inspection. The assistant managers undertake some of the supervision and keep the records in their personal lockers. This could not be accessed by the manager Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 19 or the inspector. A requirement has been made in relation to this, restated from the previous inspection. The quality assurance questionnaires including those for professionals must be sent out and the results of these questionnaires must be collated into a report and sent to he CSCI area local office. A requirement made at the previous inspection that has been restated at this inspection. 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 certificate for the water system was in order. The electrical certificate was in order. The gas safety certificate had been updated, a requirement made at the previous inspection. The manager, supported by the management committee, have acted upon the requirement in the last report that a review of the approach of a named member of staff be undertaken. This situation need ongoing monitoring by the manager. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 20 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 3 3 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 4 13 3 14 3 15 4 COMPLAINTS AND PROTECTION Standard No Score 16 X 17 X 18 3 2 3 3 3 3 3 2 3 STAFFING Standard No Score 27 3 28 3 29 1 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score X X X X X 2 X 2 Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 21 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 OP7 Regulation 15 Requirement Timescale for action 01/03/06 2. OP8 12 3. OP29 17 4. OP29 17 The resident must be supported to have an annual care plan review meeting with their care manager. Restated from the previous inspection, timescale not met 31/07/05. The staff must ensure that the 01/01/06 footrests are used on the wheelchairs. Restated from the previous inspection, timescale not met 30/04/05. All the staff files must contain a 30/01/06 copy of the member of staffs I.D. and where appropriate a copy of the authorization to remain and work in the country. Restated from the previous inspection, timescale not met 31/05/05. Immediate Requirement 10/12/05 In relation to the two care staff working at the home without a recent CRB certificate the registered person must ensure that no care staff are employed without a valid CRB certificate and the two care staff concerned must be supervised at all times until satisfactory CRBs are received. The registered person DS0000010421.V265256.R01.S.doc Version 5.0 Church Walk House Page 22 5. 6. OP7 OP9 15 13 7. OP30 18 8. OP30 18 9. OP36 18 10. OP36 18 11. OP33 24 12. OP38 23(b) must complete a POVA First check for the relevant staff. The resident who refuses to use footplates must have this recorded in his care plan. Medication must be clearly recorded on the MAR sheet and the temperature of medication must not exceed 25°C. All new staff must have a recorded induction training programme. Restated from the previous inspection, timescale not met 31/07/05. All staff must have an individual training record including copies of their training certificates. Restated from the previous inspection, timescale not met 30/06/05. All the staff must receive regular individual supervision at least every two months. Restated from the previous inspection, timescale not met 31/05/05. The supervision records must be stored so that they can be accessed by the manager as required. Restated from the previous inspection, timescale not met 31/05/05. The manager must resend the quality assurance questionnaires that have not been responded to and collate these and an action plan must be prepared. Restated from the previous inspection, timescale not met 31/07/05. The registered person must ensure all fire exits are kept clear. 01/01/06 10/12/05 30/01/06 15/02/06 20/01/06 10/12/05 10/02/06 08/12/05 Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 23 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 OP33 Good Practice Recommendations Staff should keep a record of all medical appointments logged in one book, which would provide easy access and evidence that residents’ health needs are met. A copy of the medication prescription should be attached to the MAR sheet. The manager could place the compliment cards in a folder or on a notice board to highlight the service and staff teams’ achievements. Church Walk House DS0000010421.V265256.R01.S.doc Version 5.0 Page 24 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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