Inspection on 16/06/06 for Churchfield Care Centre

This inspection was carried out on 16th June 2006.

CSCI has not published a star rating for this report, though using similar criteria we estimate that the report is 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 found there to be outstanding requirements from the previous inspection report but made no statutory requirements on the home.

Other inspections for this house

Churchfield Care Centre 12/01/06

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 Key Unannounced Inspection 16th June 2006 11:00 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.V299659.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. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 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.V299659.R01.S.doc Version 5.2 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. 12th January 2006 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 grounds surrounding these units are extensively landscaped and surrounded by large, mature trees. The residential and nursing units each have an area available for car parking and also extensive garden areas for service users to use during the warmer weather. 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 8 people of 55 and over suffering dementia. This unit, although sited within the nursing home is self contained and residents with nursing needs arising from their dementia cannot be admitted to the nursing unit. Fees within the centre range from £277 through to £485 depending on whether residential, high dependence or nursing needs. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on the 16th June 2006. Starting at 10.30am, over a period of 7 hours, the main emphasis during this inspection was on the nursing unit. The residential and dementia units were also toured and service users and staff spoken with. The manager of the residential unit, Jane Innis, assisted with both the residential and nursing unit inspection. The administrator within the nursing unit also assisted as all staff records and policies and procedures are kept in this office. The post of manager of the nursing unit is again vacant, the current manager having left the day before the inspection. Present, representing the Southern Cross organisation was Christine Hockley, Acting Operations Manager. The method used to carry out this inspection was case tracking, where Service users were spoken with about their experiences and expectations of living at the home, a tour of the home undertaken, 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; together with analysis of available records. Pine Tree Lane, now full, was toured and service users and staff spoken with. The facilities and staffing within this unit continue to be of a high standard and kept separated from the general nursing unit by a combination security locked door. All the judgements made in this report have been made using all this available evidence, including the visit to the service. What the service does well: During the inspection the grounds were being maintained, grass being mowed and the service users from the residential unit were outside in the sunshine, enjoying the peaceful surroundings and a drink under shading umbrellas. The service users expressed their satisfaction at the care they receive and particularly of the quality of food they enjoy. They also said how much they enjoyed the serenity of the grounds, surrounded by trees and shrubbery. Visitors seen also said they were treated with respect and welcomed at all of the units. This was observed during the day and each unit welcomed visitors. The Pine Tree Unit is well set out and the rooms are personalised and comfortable. Service users said they were very satisfied with their surroundings here. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 6 The nursing unit staff and service users were observed to have a positive and supportive relationship. The day was hot and there were frequent drinks supplied during the day, with those who were reluctant, being prompted. Here too the service users praised the food that was served to them and the choices they are given. What has improved since the last inspection? What they could do better: 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.V299659.R01.S.doc Version 5.2 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 Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 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): 3,5,6 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The home has information for service users to make an informed choice. They are encouraged to visit and assess the home. The needs of service users are assessed and plans made to address these. Service users referred for intermediate care are helped to maximise their independence. EVIDENCE: Service users spoken with said they had enough information to make the choice of whether to move into the home and also that they had opportunities to look around and visit the home. Assessments of needs were seen in the care plans case tracked and service users spoken with confirmed they had been asked about their needs. Service users admitted for intermediate care said that they were encouraged to be as independent as possible and this helped them prepare for going back home. This was observed during the inspection as a service user case tracked Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 9 had been admitted for periods of respite care. The care plan also identified this service user’s needs for independence. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 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 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Staff treat the service users with respect and their needs are met as set out in the care plans. Procedures in place for administration and self administration of medicines. EVIDENCE: Care plans viewed in all the units contain thorough pre-admission assessments and plans which identify and address the needs and risks. Service users spoken with said they were aware of a plan of care and that the staff did their best to meet their needs. They also said that staff treated them with dignity and always knocked before entering their rooms and that they worked hard to ensure privacy. The positive, supportive interactions between staff and service users was observed in all three units during this inspection and staff were seen knocking on doors and waiting before entering service users’ rooms. Policies and procedures for self medication were seen during this inspection, but no-one was seen to self medicate during the inspection. However, the Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 11 Medicines Administration Records were accurately completed and lunchtime administration of medication was observed to be carried out in accordance with the set out procedures. All medicines were appropriately stored and locked away. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 12 Daily Life and Social Activities The intended outcomes for Standards 12 - 15 are: 12. 13. 14. 15. Service users find the lifestyle experienced in the home matches their expectations and preferences, and satisfies their social, cultural, religious and recreational interests and needs. Service users maintain contact with family/ friends/ representatives and the local community as they wish. Service users are helped to exercise choice and control over their lives. Service users receive a wholesome appealing balanced diet in pleasing surroundings at times convenient to them. The Commission considers all of the above key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 12,13,14,15 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The activities within the residential unit have been implemented to meet recreational needs. Contact with family and friends is encouraged and visitors are welcomed. Service users are encouraged to exercise choice. The food within all the units is appealing, balanced and provided in pleasant surroundings. EVIDENCE: The residential unit has introduced a programme of activities and this included trips to Skegness and Twycross zoo, which service users said were “great trips” and they also said that there are more activities within the residential unit now, which “improves the day”. The activities in the nursing and dementia units continue a service user said that “I have painted a picture for my daughter”. During the inspection, on a day that was quite warm and sunny, there were a number of activities being carried on around the units, some outside and the atmosphere these activities generated was positive and cheerful. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 13 Visitors are welcomed in the units and this was observed during the inspection as visitors arrived throughout the day. Service users said the staff always made their families feel welcome. Staff were observed encouraging service users to make decisions, discussions on what they would like to do were heard. Meals provided were wholesome, appeared appetising and balances and choices were available. There were frequent drinks offered throughout the day, which continued to be hot. Service users said they enjoyed the food very much and that there were choices. “If I don’t like what’s on offer they will get me something else.” “The staff know what I don’t like and make sure I don’t get anything I don’t like.” The dining areas in all units are pleasantly furnished, decorated and bright. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 14 Complaints and Protection The intended outcomes for Standards 16 - 18 are: 16. 17. 18. Service users and their relatives and friends are confident that their complaints will be listened to, taken seriously and acted upon. Service users’ legal rights are protected. Service users are protected from abuse. The Commission considers Standards 16 and 18 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 16,18 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. Complaints are listened to and taken seriously. Service users are protected from abuse. EVIDENCE: The complaints procedures explains the complaints process and what to do if unhappy with the response to any complaint. Service users, staff and visitors all said they were aware of how to make complaints, and that the staff were always willing to listen. Staff spoken with were aware of their roles in the procedures for safeguarding adults and the Adult Protection policy is in place and up-to-date. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 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): 19,20,23,25,26 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. All units are clean and hygienic. They are all generally well maintained, but there are some areas within the communal facilities requiring attention. Service users rooms suit their needs and the home is safe with comfortable surroundings. EVIDENCE: All units were observed to be clean and hygienic with no odours in any areas. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 16 The service users said they were very happy with their own rooms and these were observed to be clean, well furnished and had service user’s personal possessions in them. One service user said that “this is almost like being at home.” Maintainance inside and outside all three units is carried out by one person. During the inspection work was being done on the lawns and in the garden. The home is surrounded by mature trees and the gardens are pleasantly landscaped, with seating areas placed around each unit. Any maintenance issues are written in the maintenance book, seen at this visit, and then dealt with in order of priority. However, with such a large garden and three units to maintain, routine, regular, maintenance of paintwork within the units has not been carried out. This gives a “tired” impression within the communal areas, especially in the nursing unit with scuffs and chips in the paintwork on doors and along the corridors. Service users outside the residential unit said how much they enjoyed the peace and tranquillity provided by the garden area. “Its lovely to hear the birds and not the traffic,” was the comment from one service user. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 17 Staffing The intended outcomes for Standards 27 – 30 are: 27. 28. 29. 30. Service users’ needs are met by the numbers and skill mix of staff. Service users are in safe hands at all times. Service users are supported and protected by the home’s recruitment policy and practices. Staff are trained and competent to do their jobs. The Commission consider all the above are key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 27.28.29.30 Quality in this outcome area is excellent. This judgement has been made using available evidence including a visit to this service. The staff numbers and skill mix meet the needs of the service users and they are protected by robust recruitment policies, which are followed. Staff receive training and are competent to do their jobs. EVIDENCE: Duty rotas for all units showed appropriate numbers of staff and skill mix to meet the needs of the service users. Which included the appropriate number of trained nurses within the nursing unit. Staff spoken with said that on occasion there didn’t seem to be enough staff on, but mostly there is. The number of staff on duty during the inspection appeared sufficient to meet the needs of the service users. Service users said they were happy with the staffing levels. “They come very quickly when I need them.” The case tracked staff files contained evidence of good recruitment practices, which included application forms, Criminal Records Bureau checks, satisfactory references, Nursing and Midwifery Personal Identification Number checks, where necessary. Staff spoken with said that they did receive training and this was recorded in staff files. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 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): 31,33,35,36,38 Quality in this outcome area is good. This judgement has been made using available evidence including a visit to this service. At present there is no registered manager within the nursing unit and supervision of staff is not recorded as being carried out. The home promotes the health, safety and welfare of its service users and staff and run the home in the best interest of the service users. EVIDENCE: The acting manager of the nursing unit has now left and this leaves the registered manager’s position vacant. There is support from the Southern Cross regional management and this was observed during the inspection. Although the manager had left the staff spoken with said they felt they were still supported. The trained staff said that more pressure was put onto them, but that they also had support from the regional management. The residential Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 19 unit is run by the deputy manager Jane Innis, who also supports staff in the nursing and dementia units when necessary. The regional manager said that advertisements for a new manager were being prepared. Service users spoken with said they “feel the home is run to help me” “some homes seem to be for the staff, but not this one.” Service user finances were being audited during the inspection and individual accounts, expenditure and receipts were noted. Money is kept separately and locked safely away, with access whenever service users needed this. Staff files case tracked did not contain any evidence of supervision or appraisal being carried out. Staff did say that they had had supervision and this was confirmed by the administrator. However, there was no written evidence within the home of this being carried out. The fire alarm testing and other mandatory servicing and safety tests and records are kept by the maintenance man, which were found to be regularly carried out, up to date and in order, including servicing of lifts and electrical appliances. Staff said that fire alarm testing was carried out regularly and service users spoken with also said this was regularly carried out. Appropriate insurances were also noted to be in order. Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 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 N/a N/a 3 N/a 3 3 HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 N/a DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 N/a 18 3 2 3 N/a N/a 3 N/a 3 3 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 N/a 3 N/a 3 2 N/a 3 Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 21 Are there any outstanding requirements from the last inspection? yes STATUTORY REQUIREMENTS This section sets out the actions, which must be taken so that the registered person/s meets the Care Standards Act 2000, Care Homes Regulations 2001 and the National Minimum Standards. The Registered Provider(s) must comply with the given timescales. No. 1 Standard OP31 Regulation 9(2) Requirement The Nursing Home and Pine Tree 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 (Requirement made at previous inspection 12/01/06 but acting manager left 16/06/06) Timescale for action 25/09/06 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 OP19 Good Practice Recommendations To carry out maintenance to areas within units which have chipped and scuffed paintwork. DS0000024635.V299659.R01.S.doc Version 5.2 Page 22 Churchfield Care Centre 2 OP36 Care staff in all units to receive 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 worker. All other staff to be supervised as part of the normal management process on a continuous basis Churchfield Care Centre DS0000024635.V299659.R01.S.doc Version 5.2 Page 23 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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