Inspection on 12/01/06 for Churchfield Care Centre

This inspection was carried out on 12th January 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is Good. 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

Churchfield Care Centre 16/06/06

Churchfield Care Centre 16/08/05

Churchfield Care Centre 10/11/04

Churchfield Care Centre 24/05/04

Churchfield Care Centre 25/02/04

Similar services:

Byars Care Home

St Marys Nursing Home

Bramble Lodge

Parkmanor Residential Home

Thornham Grove

Hunter`s Lodge

London Road Neurological and Specialist Care Unit

Carlton Care Home

Extracts from inspection reports are licensed from CQC, this page was updated on 08/07/2008.

CARE HOMES FOR OLDER PEOPLE Churchfield Care Centre Churchfield Drive Rainworth Nottinghamshire NG21 0BJ Lead Inspector Lee West Unannounced Inspection 12th January 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 Churchfield Care Centre DS0000024635.V277002.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. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 3 SERVICE INFORMATION Name of service Churchfield Care Centre Address Churchfield Drive Rainworth Nottinghamshire NG21 0BJ 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) 01623 490109 01623 795060 Southern Cross Care Homes No 2 Limited Vacant Care Home 60 Category(ies) of Dementia (8), Dementia - over 65 years of age registration, with number (8), Old age, not falling within any other of places category (58) Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. 6. Registered Manager must be 1st Level Nurse and full time,with full time supernumery hours of work. Assistant Manager (Head of Care of Residential Unit) to have at least 2 days Supernumery hours of work. Administration support for at least 25 hours a week Residential Unit to allow 22 service users of residential category (older people) only. Five Clients, in the category OP, over the age of 60 Residents falling within the category of Dementia aged 55 and over can be admitted to the part of the home known as Pine Tree Lane. Pine Tree Lane has been set up to provide an appropriate and safe environment. Residents with nursing needs arising from their Dementia cannot be admitted to the home. 16th August 2005 7. Date of last inspection Brief Description of the Service: Churchfield Care Centre, situated within the mining community at Rainworth, close to local amenities, provides care within three separate units. The first unit provides residential care for 22 older people, the nursing unit provides 38 places for older people who require nursing care. Recently opened within the nursing unit is the Pine Tree Lane unit, providing care for people of 55 and over suffering dementia. This unit, although sited within the nursing home is self contained. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 12th January 2006, and commencing at 11.45, was over a period of 6 hours. The main emphasis within this report was the residential unit, although the nursing and dementia units were toured and inspected as well. The method used was Case Tracking where Service users were spoken with about their experiences and expectations of living at the home, with analysis of the records and talking with members of staff to ensure that those living at the home have their needs met and their health and welfare maintained appropriately. The Manager of the residential unit, Jane Innis, assisted during the major part of the inspection. This unit has 19 service users at present. Olive England, acting manager of the nursing unit, was present during the nursing home and dementia unit inspection, assisting with the tour and answering questions. Records are kept within the nursing home administration office, and these were viewed. At the time of inspection there was no-one in post as manager of the nursing unit as the previous manager has been promoted within the company and Olive England is acting manager. Some of the service users feel that they would like some stability as there hasn’t been a “proper person in charge” for quite some time. The new Pine Tree Lane unit was toured and service users spoken with. The facilities and staffing within this unit were of a high standard and kept separated from the general nursing unit. What the service does well: Service users in the residential unit and the Pine Tree Lane unit said they were satisfied with the care they receive. The food is very good and that they treat service users and their visitors with respect and are always helpful. The Pine Tree Unit is well set out, pleasantly decorated with tactile wall decorations and comfortable communal and personal rooms. Service users in this unit expressed their approval of the surroundings. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 6 The care plans case tracked (residential unit)during the inspection were well presented with thorough risk assessments and updating. The service user care plans tracked within the nursing unit and the dementia unit were also satisfactory and contained the appropriate information. During the visit the maintenance man was seen to be carrying out the routine maintenance. He takes care of all units and the gardens, is a trained electrician and maintains the units in good order. What has improved since the last inspection? What they could do better: There is no formal, regular, daily activities programme in place for the service users within the residential unit and the service users feel that this is “making the days very long”. They also said they would like activities which “make my brain work.” There was a pantomime at Christmas and a trip to Skegness during the year, but no real day to day activities. The nursing unit do have an activities co-ordinator, as does the Pine Tree Lane unit. Supervision of care staff is not regularly carried out and this is evidenced within the staff files. Staff files viewed did not have current photographs of the staff, but there was evidence of identity in photocopies of passport photographs. Wheelchairs were observed being stored within the Quiet Activities room in Pine Tree Lane which obstructed the use of the room. The Nursing Home and Pine Tree Lane Units require a Registered Manager, suitably qualified to be appointed and registered with the Commission. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 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. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 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 Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 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 at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1,2,3,4,5, The home has information for the service user to make an informed choice. There were no written contracts seen. Pre-admission assessments are completed and plans begun. Service users and relatives are welcomed to visit and assess the home. EVIDENCE: Service users said that they did receive relevant information to make a decision about coming into the home and could visit if they wished. One relative said that the information given and staff helpfulness helped with the decision of whether to come into the home or not. Service users said they were unaware of any contracts and none were seen in the files case tracked. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 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): 7,8,10, Care plans seen meet the needs of service users and staff do treat the service users with respect. EVIDENCE: The care plans viewed in the residential unit contain a thorough pre-admission assessment and plan, which addresses the needs and risks assessed. The service users spoken with said they are treated with respect and the staff always knock, before entering the personal rooms. Care plans seen in the nursing and dementia units also identified and actioned the service users needs. The service users in these units also said they were comfortable with the way the staff treat them and that they do knock on doors. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 11 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 There is a serious lack of activities within the residential unit. However activities are addressed within the nursing and dementia units. All units encourage contact with family and friends. The food served at all units was of a good quality, substantial portions, appetising and with choices given. EVIDENCE: The residential unit does not have any regular opportunities for stimulation through leisure and recreational activities in the home. There have been visits to Skegness and Christmas activities, but day to day the service users “feel the days just drag” “I get fed up with watching the tele”. A structured programme to meet the interests of the service users would enhance the quality of life within the home. The nursing unit does have an activities co-ordinator and sometimes the service users from the residential unit have been invited up. However, service users expressed that “it just makes me think of what’s coming, so I don’t like to go”. The Pine Tree Lane unit also has activities organised regularly and some results of these activities were seen during the tour of the unit. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 12 The service users spoken with feel that due to the lack of activities available their choice and control is limited. They also said that due to staff being short at times they have less choice in what they would like to do. Service users and their relatives, spoken with during the inspection, were positive about the staff’s support in maintaining contact. During the inspection, the inspector observed a relative, who arrived to visit, welcomed warmly and presented with a warm drink on arrival. The two meals observed during this inspection were pleasantly presented, served in well set out dining rooms. The food was appetising, with “plenty of it” and “its really good” the service users said. They also said that if they didn’t like something, choices are given. Service users in all three units said they were very satisfied with the food provided. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 13 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 Service users and relatives feel confident about making complaints and suggestions. EVIDENCE: Relatives and service users spoken with were aware of how to make complaints and they said the staff were all approachable. The complaints procedure explains what service users or relatives should do complain and also what to do if they are unhappy with the response to the complaint. Staff are aware of the procedures if they suspect that abuse might have taken place. The Adult Protection policy is in place and staff spoken with explained their role in this area. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 14 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 The home is well maintained, clean with access to comfortable indoor and outdoor facilities. There are sufficient toilet and washing facilities and the residential unit was clean, pleasant and hygienic. The nursing unit did, in the lounge area, have a slight odour, and the Pine Tree Lane unit was clean, pleasant and hygienic, brightly decorated and well furnished. EVIDENCE: The maintenance is carried out by Gary, who has been working at the home for about a year. He is responsible for all the units. During the inspection the maintenance book, and scheduled safety check records were seen. Gary said that he deals with emergencies first and then plans routine and regular maintenance. During the inspection shelves were being put up. The décor in all units is well maintained. The gardens are well kept and this is also the responsibility of the maintenance man. All units were toured during this inspection and all provide sufficient toilet and bathing facilities. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 15 The facilities in Pine Tree Lane are spacious, clean and well decorated. The unit was fitted out with a range of good quality communal and personal furniture, with service users having their personal possessions around them. Service users said they were “very happy” and “comfy” when describing their own rooms. The residential and nursing units are well laid out and there were items of specialist equipment in both of these units. There was an electric wheelchair being used in the residential unit and both have hoists and mobility aids which were observed being used during the inspection. A malodour was detected within the lounge area of the nursing unit, but the Residential Unit, was thoroughly clean and hygienic with no odour. Service users within the residential unit expressed their satisfaction with their rooms and all had their personal possessions around them. Relatives spoken with during the inspection also expressed their satisfaction at the environment in and around the residential unit. Saying it is always “clean and smells nice.” Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 16 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 staff numbers and skill mix on the three units meets the needs of the service users. Recruitment processes support protection of the service users and staff receive training. The Nursing unit and Pine Tree Lane do not have a Manager. EVIDENCE: The nursing unit and Pine Tree Lane, within the nursing unit, do not have a registered manager and service users feel that things are “a bit chaotic”. They said it is “unsettling to have these constant changes of people”. Mrs Jane Innis is the manager of the residential unit and service users in this unit said they felt the staff “work very hard” “Jane does hands on work” “sometimes there isn’t enough staff on”. The duty rotas seen showed appropriate numbers and skill mixes, for the week of the inspection, of staff on duty in all the units. The staff files case tracked contained evidence of good recruitment practices, including the Criminal Records Bureau checks and satisfactory references. The staff files also contained certificates of training received by the staff and staff interviewed during the inspection confirmed that they do have training. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 17 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): 31,32,33,36,37,38 The Residential unit does have a registered manager, but the nursing and Pine Tree Lane units do not. The home promotes the health, safety and welfare of the service users and their rights are safeguarded. Supervision of staff does not take place regularly within the units. EVIDENCE: As stated in the previous standard, the Nursing and Pine Tree Lane units do not have a registered Manager. The previous manager has been promoted within the company and the position has been vacant for some time. Olive England is acting manager at present. Service users feel “unsettled” because of this and unsure who is in charge. The Residential Unit is managed by Jane Innis, who works with the service users and has supernumerary hours to deal with the management responsibilities. The service users in this unit said they feel “comfortable” as Jane works with them when she is on duty. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 18 The home, as a whole, is run in the best interests of the service users and those spoken with in all the units confirmed this. However, in the Residential Unit, the service users are unhappy with the lack of activities and mental stimulation. The policies and procedures within the homes are followed and staff said they were aware of these and that they followed them. The care plans were well set out and kept within each unit and all other records are kept confidentially in the administration office within the Nursing unit. The maintenance, fire and health and safety checks and records are all completed by Gary, the maintenance man. The records were viewed during the inspection and found to be properly completed. The service users within all the units expressed their satisfaction that the staff did try to work in their best interests. Staff files viewed did not contain any evidence of staff supervision or appraisal and staff said they had not received regular supervision. Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 19 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 3 3 3 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 X 10 3 11 x DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 1 13 3 14 2 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 3 3 3 3 3 3 3 3 2 STAFFING Standard No Score 27 3 28 3 29 3 30 3 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 2 3 3 x x 2 3 3 Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 20 Are there any outstanding requirements from the last inspection? none 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 OP12 Regulation 16(2)m Requirement Timescale for action 28/02/06 2 OP12 16(2)n 3 OP31 9(2) 4 OP36 18(2) The Registered Person shall consult service users about their social interests and make arrangements to enable them to engage in local, social and community activities, within the Residential Unit The Registered Person shall 28/02/06 consult service users and arrange a programme of activities providing facilities for recreation, having regard to the needs of the service users, within the Residential Unit The Nursing Home and Pine Tree 30/03/06 Lane units employs a Registered Manager who is qualified, competent and experienced to run the home and meet its stated purpose, aims and objectives and is registered with The Commission for Social Care Inspections as a priority Care staff in all units to receive 30/03/06 formal supervision at least 6 times a year, which covers all aspects of practice, philosophy of care in the home and career development needs of the care DS0000024635.V277002.R01.S.doc Version 5.1 Churchfield Care Centre Page 21 worker. All other staff to be supervised as part of the normal management process on a continuous basis 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 OP22 Good Practice Recommendations Storage Areas are provided for aids and equipment, including wheelchairs and these should not be stored in the Quiet Activities Room (Pine Tree Lane) Churchfield Care Centre DS0000024635.V277002.R01.S.doc Version 5.1 Page 22 Commission for Social Care Inspection Nottingham Area Office Edgeley House Riverside Business Park Tottle Road Nottingham NG2 1RT 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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