Inspection on 12/10/05 for Churchfield Court

This inspection was carried out on 12th October 2005.

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 Court 18/10/07

Churchfield Court 02/08/06

Churchfield Court 09/05/05

Churchfield Court 10/11/04

Churchfield Court 15/06/04

Churchfield Court 11/02/04

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Maple Lodge

Heathlands

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Breme

Ravenhurst

Bank House

Inspirations

Ashcroft Hollow Nursing Home

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

CARE HOMES FOR OLDER PEOPLE Churchfield Court All Saints Way West Bromwich West Midlands B71 1RR Lead Inspector Mike Kirton Unannounced Inspection 12th October 2005 09:15 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 Court DS0000004842.V257730.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. Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Churchfield Court Address All Saints Way West Bromwich West Midlands B71 1RR 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) 0121 588 5450 0121 588 5450 Mr Anand Gunputh Mrs Amrita Gunputh Patricia Yvonne Dunkley Care Home 37 Category(ies) of Old age, not falling within any other category registration, with number (37) of places Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 9th May 2005 Brief Description of the Service: Churchfield Court is a residential care home registered to provide 24-hour care for 37 people over the age of 65. It is located on the A4031 (All Saints Way) at the junction of Newton Road and Heath Lane, opposite All Saints Church. West Bromwich town centre, Sandwell General Hospital and Sandwell Valley Park are nearby and there is easy access to public transport networks. The home was purpose built for the care of the elderly and has twice been extended. There is a small patio area and gardens at the rear of the property with a raised shrub border. Paths extend round to the front where ample parking is available. Accommodation is provided over two floors with access to the first floor via the main staircase and passenger lift. There are 31 single and 3 twin bedrooms all of which have en-suite toilets and washbasins. Communal space includes 3 lounges and 2 dining rooms. Sufficient bath and shower facilities are also available. Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. The inspection took place over 6 hours and included discussions with 15 residents, 2 visitors, the manager and 7 staff members. A tour of the buildings took place and 3 care plans were examined. Additionally the homes assessments of resident’s dependency were checked along with current staffing levels. What the service does well: 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 Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 6 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 Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 7 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): These standards were not fully assessed on this occasion. Please refer to the last report dated 9th May 2005. EVIDENCE: Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 8 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): These standards were not fully assessed on this occasion. Please refer to the last report dated 9th May 2005. EVIDENCE: Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 9 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 good range of activities provided both inside and outside the home. Residents are able to make their own choices about their daily life and are encouraged to voice any concerns or opinions they may have. EVIDENCE: A daily plan of activities is provided, which are listed in reception including bingo, card games, armchair exercises, and quizzes. These are all carried out by care staff and take place in the main lounge. There is a large selection of books available in large print and the mobile library visits the home. There is a TV, video/DVD player, large calendars and clocks, (displaying the correct time and date), in both lounges. The home also has a pet budgie. Several outings are arranged throughout the year including a trip to the Backcountry Living Museum, Walsall lights and the pantomime. The manager has now implemented a rota to ensure all residents have a trip out at least once every 2 months. Regular residents meetings are held to receive feedback and provide information about what is happening within the home. Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 10 A choice of meals is provided and a menu displayed. Each day a staff member is given the responsibility of speaking to each resident for his or her preference. Hot and cold drinks are provided throughout the day and staff were seen to ensure that these are taken. All individual requirements are catered for and specialist diets provided. When need fluid intake charts are used to reduce the risk of dehydration. The home has a visitor’s policy in reception. Residents may receive guests at any reasonable time or with prior agreement. They may be seen in either the communal areas or the privacy of their own room. Residents and/or their relatives are responsible for their own finances. The home holds a small amount for them if requested, to pay for such things as hairdressing. Contact details for a local advocacy service are displayed and all personal records are kept securely in the main office. Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 11 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): 16,17,&18 The home has taken appropriate measures to ensure that residents are protected from abuse and staff have a good knowledge of their responsibilities. Comments and complaints are welcomed by the manager and are used to improve the service provided. EVIDENCE: The homes complaints procedure is clearly displayed in reception and includes the contact number and address for the Commission. Forms and envelopes are also provided to encourage feedback from residents and visitors. Complaints received during the year have been investigated and their findings acted on immediately. Residents are enrolled on the electoral register and may either vote by post or attend their local ballot station. Details on advocacy services are also displayed in reception. There have been no allegations of abuse reported in the home. All staff interviewed are aware of the policy on whistle blowing and their responsibility to report any suspicion of abuse taking place. Training in adult protection has been provided and all the required procedures have been implemented. Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 12 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): These standards were not fully assessed on this occasion. Please refer to the last report dated 9th May 2005. EVIDENCE: Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 13 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): These standards were not fully assessed on this occasion. Please refer to the last report dated 9th May 2005. EVIDENCE: Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 14 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 The manager continues to make improvements to the way in which the home is operated and welcomes feedback from residents and visitors to the home. Appropriate actions are taken to ensure the health and safety of everyone at Churchfield Court is protected. EVIDENCE: Patricia Dunkley was successful in becoming the registered manager of Churchfield Court in May 2005. She has the NVQ level 4 in Management and Care and has continued to attend further training courses as needed. Following many years experience working in care she obtained the position of Acting Manager in August 2005. Since appointment she has implemented many changes to the organisation and worked open and honestly with the Commission. Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 15 The home was inspected recently by the fire service who considered all matters relating to safety to be satisfactory. The manager submitted written confirmation that all required health and safety checks were being completed. All fire fighting equipment is serviced annually and food and water temperatures recorded. Action is required to replace a door lock to one room, which must be fitted with an override device. Questionnaires have been developed to obtain the views of residents, relatives, and other visitors to the home. Some of these have been returned and the manager is in the process of getting these ready for publication. These must be reviewed on a annual basis and actions taken to improve on the standards. Regular staff and residents meetings take place throughout the year and requirements made by the Commission are met within the agreed timescales. There are several policies and procedures, which still require implementing within the home. The manager must sign and date these and provide evidence that staff have read and understood them. These must be reviewed on an annual basis, or as required. Either the resident or their relative manages all finances. The home does hold a small amount if requested for safekeeping. Two staff are required to sign and witness any transaction that takes place. These records were examined and found to be in good order. Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 16 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 X X X N/A HEALTH AND PERSONAL CARE Standard No Score 7 X 8 X 9 X 10 X 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 3 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 4 17 3 18 3 X X X X X X X X STAFFING Standard No Score 27 X 28 X 29 X 30 X MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 3 X 2 Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 17 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 OP33 Regulation 12&13 Requirement Continue to develop the homes quality assurance system and publish the results on an annual basis. An improvement plan should be implemented based on the results. Repair the bedroom door (9) and replace the lock to enable staff to gain entry in a emergency. Ensure all policies and procedures are implemented, signed and dated by the manager, and reviewed at least every year. Timescale for action 01/03/06 2 3 OP38 OP38 23 12&13 01/11/05 01/01/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. No. Refer to Standard Good Practice Recommendations Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 18 Commission for Social Care Inspection Halesowen Record Management Unit Mucklow Office Park, West Point, Ground Floor Mucklow Hill Halesowen West Midlands B62 8DA 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. Extracts may not be used or reproduced without the express permission of CSCI Churchfield Court DS0000004842.V257730.R01.S.doc Version 5.0 Page 19 - 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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