Inspection on 02/08/06 for Churchfield Court

This inspection was carried out on 2nd August 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 Court 18/10/07

Churchfield Court 12/10/05

Churchfield Court 09/05/05

Churchfield Court 10/11/04

Churchfield Court 15/06/04

Churchfield Court 11/02/04

Similar services:

Maple Lodge

Heathlands

Aston Court Nursing Home

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 Mrs Maggie Bennett Key Unannounced Inspection 08:45 2nd August 2006 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.V305660.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 Court DS0000004842.V305660.R01.S.doc Version 5.2 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.V305660.R01.S.doc Version 5.2 Page 4 SERVICE INFORMATION Conditions of registration: Date of last inspection 12th October 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. Fees charged at the home range between £335.00 and £365.00 per week. Churchfield Court DS0000004842.V305660.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 a weekday between 8.45 a.m. and 6.00 p.m. During the course of the day a number of service users were spoken to, as well as 2 visitors and 4 staff members, plus the Registered Manager. The assessment information of newly arrived service users was seen and 5 Care Plans were inspected. Staff rotas and 4 staff files were seen. Prior to the inspection an anonymous questionnaire was completed by 9 service users and these were forwarded to the Commission. In addition the Registered Manager completed a Pre Inspection Questionnaire. A tour took place of all the communal areas of the building and of the majority of bedrooms. Various documents were seen in order to check compliance with health and safety legislation. On this occasion all the Key Standards of the National Minimum Standards were assessed. Three statutory requirements were made following the inspection on 9th May 2005 and 3 further statutory requirements made following the inspection on 12th October 2005. All these requirements have now been met. 9 statutory requirements have been made following this inspection. What the service does well: What has improved since the last inspection? Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 6 All the statutory requirements made at the last 2 inspections have now been met. Service users now sign to consent to taking medication. A full induction programme has been introduced for all new staff. The home have improved the way they obtain the views of service users and relatives and anticipate that they will extend this exercise to cover visiting social and healthcare professionals. The Manager ensures that all policies and procedures are regularly reviewed and updated as necessary. 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.V305660.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 Court DS0000004842.V305660.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. Standard 6 is not applicable. The overall outcome for this group of Standards is judged to be Good. There are good admission procedures in place, to ensure that service users can be confident that their needs will be properly assessed prior to them moving to the home. EVIDENCE: The assessment information of 3 service users, who had moved to the home relatively recently, were seen at the inspection. One of these was a service user who was privately funded. In this instance a representative from the home had visited the service user and had carried out a proper assessment. A copy of this assessment was seen on file. This included all those details required by Standard 3.3 of the National Minimum Standards, with the exception of sufficient detail on family involvement and social contacts. The two other files seen contained a copy of the Sandwell Social Services Single Assessment Process document. All assessments contained a falls risk assessment and risk assessment checklist. These are comprehensive documents and contain all the required elements. It is recommended, Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 9 however, that the home produce a “Pen Picture” of the service user in which brief details are given of their personal history as well as information of the contact and support they can anticipate from family and friends when they move to the home. Following assessment, the Registered Manager writes to the prospective service user confirming that the home will be able to meet their needs. Churchfields Court does not offer intermediate care. Churchfield Court DS0000004842.V305660.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 and 10. The overall outcome for this group of Standards is judged to be Good. There are clear care plans in place, which are regularly reviewed. These ensure that individual service users’ personal and healthcare needs are clearly stated and interventions put in place so that these needs are met. The systems for the administration and recording of medication are sound and protect service users. Service users feel that their rights to privacy are respected. EVIDENCE: All service users have a Plan of Care, which is generated from the assessment information. There was evidence that service users are involved in the development of this plan. Those who are able to are asked to sign a Care Plan Agreement. In some cases, these agreements had been signed by the service user’s next of kin. Care plans are clear and set out in detail the action which needs to be taken by staff to ensure that service users’ personal and healthcare needs are met. They include risk assessments. It is recommended that more detail is provided on the process of care, i.e. how the service user Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 11 likes the intervention to be carried out. Care plans contain details of regular reviews. It is recommended that when the monthly review has taken place, the care plan is signed and dated by the reviewer to confirm that the review has taken place. Service users’ healthcare needs are detailed within their care plans. It was noted that one service user had a pressure sore and that the home, having identified this, were taking appropriate action and this was clearly recorded. The District Nurse was visiting on a regular basis and the home’s interventions, such as turning and the provision of specialist equipment were noted on the Care Plan. Another person was diabetic and this was also clearly noted on the Care Plan. The cook was spoken to and she explained that sweets and cakes were prepared for this person without sugar. Another care plan set out how a person’s needs with regard to pain relief were to be met. All care plans seen contained a pressure sore risk assessment and nutritional screening. Service users are able to register with a local G.P. of their choice and all the G.P.s carry out a yearly review of individual service users’ medication. Other healthcare professionals, such as the chiropodist, dentist and optician visit the home on a regular basis. In their returned surveys, 8 out of 9 service users said that they “always” received medical attention when they needed it. The home has a policy and procedure in place with regard to the administration of medication. Service users’ written consent to the administration of medication is obtained and copies of these were available in files seen. None of the current service users take charge of their own medication, apart from some creams. All service users do, however, have a lockable facility in their rooms in which to keep their medication, if they wish. The home uses a “Nomad” monitored dosage system. Medication arrives each week and a senior member of staff checks it off against the prescriptions and signs the Medication Administration Sheet to verify that the correct amount has been received. Controlled drugs are correctly stored, administered and recorded. A random sample of the “Nomad” packs and administration sheets were checked and there were no discrepancies. All those staff who administer medication have provided a sample copy of their signature. Ten members of staff are currently taking part in the Safe Handling of Medicines training and anticipate that they will have completed the training by the middle of August 2006. It was good to note that the home had dealt satisfactorily with a situation where a service user was consistently refusing to take medication. It had been recorded that the G.P. was consulted and the G.P.s response was recorded in the service user’s Care Plan. The majority of service users at Churchfields Court have their own rooms and, therefore, all personal care giving takes place in private. Where rooms are shared, a screen is provided, although there is no one sharing a double room at present. Service users are able to have a telephone installed in their rooms, at their own expense. There is a payphone available, but the home Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 12 also has a portable phone, which service users are able to take to their rooms if they wish. All new staff are instructed during induction on how to treat service users with respect. A service user spoken to said that staff respected her privacy and understood that she liked her own company. She said she always locked her door at night. Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 13 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 and 15. The overall outcome for this group of Standards is judged to be Good. A good range of activities are offered at Churchfields Court, both inside and out of the home. These are arranged on a regular basis and are of great benefit to those service users who wish to join in. Service users are able to make choices about their daily lives and are encouraged to voice any concerns or opinions they may have. The meals provided are of good quality and offer choice and variety. EVIDENCE: A member of staff takes particular responsibility for organising activities. Staff carry out fund raising activities. A trip to the Cotswolds has been arranged to take place in the near future. 2 service users are taken by staff to the local Church on a weekly basis. Some service users are assisted to use the Ring and Ride. Of the returned questionnaires, 4 out of 8 service users said that they were “always” provided with the opportunity to take part in suitable activities, 2 said “usually” and 2 said “sometimes”. One person said that she could not take part because she was deaf. It is recommended that the home pay particular attention to those service users who have a sensory impairment. The Registered Manager keeps an Action Plan for activities – Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 14 every 2 months service users have a trip out. There are also regular in house activities, when visiting entertainers call. A religious service takes place each month and one took place during the inspection. An in house activity takes place each day (apart from some “rest days” when service users have their nails done or watch TV). The in house activities can include bingo, “singalongs”, dancing and quizzes. There are also light exercise sessions. Service users spoken to during the inspection confirmed that they were able to choose whether or not to join in activities. Visitors are able to call at any reasonable time. Should a service user not want to see a particular visitor, their wishes would be respected. Service users are able to handle their financial affairs for as long as they wish. Most prefer their relatives to take charge of their finances. Details of local Advocacy services are available in the home, should this service be required. Service users are able to bring personal possessions with them when they move to Churchfields Court and rooms are personalised to suit individual tastes. Service users are very satisfied with the food provided at the home. The following are some of their comments: “The food is good”; “The food is marvellous”; “The food is good and is cooked well. There is a very good cook, who is very kind and will put herself out.” A visiting relative said that her mother liked the food. A service user also stated that they had been served plenty of cold drinks during the exceptionally hot weather. It is the home’s policy for a member of staff to speak with the service users the day before and ask them what they would like to eat. There is always a choice. Fresh fruit and salad are delivered each week. Fresh vegetables are not normally provided, frozen only, although none of the service users mentioned this. The cook speaks to the service users each day after the main meal to get their opinion of the meal that has been served. On Mondays and Fridays there is a cooked tea, on other days sandwiches are served at tea-time. There is a 4 week menu programme. Menus show that a variety of nutritious foods are offered. The cook stated that special foods are provided when needed. At present there are some service users who have diabetes and sugar free foods are cooked for them. The lunch time meal was observed and was much enjoyed by the service users. The majority of service users chose to have gammon, served with sauce and vegetables. Some chose to have a salad. It is recommended that the home obtain a mincer or liquidiser as one service user had great difficulty chewing the gammon because of problems with her teeth. The kitchen was seen and was found to be in good order. There were good supplies of food. Fridge and freezer temperatures are taken daily and the temperature of cooked food is taken. Records of kept of the food eaten by individual service users. Records of service users’ likes and dislikes with regard to food are also kept in the kitchen. It is recommended that when dried Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 15 foods, such as cereals and flour, are de-canted, a note is made on the container of the “best before” date and of the date of opening. Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 16 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 and 18. The overall outcome for this group of Standards is judged to be Adequate. There are sound procedures in place with regard to complaints. Service users who returned the questionnaires say that they know who to complain to and feel that they would be listened to. Service users spoken to during the inspection said the same. The home’s Adult Protection Procedure needs to be revised so that it is in line with the Sandwell Social Services Procedure and the Department of Health guidance, “No Secrets”. EVIDENCE: In their returned questionnaires, 8 out of 9 service users said that they “always” knew who to talk to if they were unhappy about anything, 8 said that they “always” knew how to make a complaint. There is a copy of the Complaints Procedure in the foyer of the home and all service users have a copy supplied in the Service Users’ Guide. The Procedure clearly sets out who to speak to in the first instance and gives timescales as to when the complainant will be responded to. It also includes information for the complainant on how to get in touch with their local Social Services office, the CSCI and the Ombudsman. No complaints have been made to the home or to the Commission since the last inspection. The home has an Adult Protection Procedure in place, but this procedure is not in line with the Sandwell Social Services Procedures or the Department of Health document, “No Secrets”. The home must obtain a copy of both Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 17 documents without delay. The home must then ensure that its own procedure is in line with these documents, particularly with regard to any investigation of the allegation. Staff were due to take part in Adult Protection training on the day following the inspection. Both the Manager and staff spoken to during the inspection were clear about their roles and responsibilities with regard to Whistleblowing and POVA. Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 18 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, 21, 24 and 26. The overall outcome for this group of Standards is judged to be Adequate. Churchfields Court is homely and comfortable. Service users live in a safe and generally well maintained environment. The home is furnished to a high standard. There are some areas, i.e. the use of door wedges and some violently closing doors, which could put service users at risk and these must be attended to. A first floor assisted bathroom, which is acceptable to the service users, must be provided. Some bedrooms need the floor covering to be cleaned or to be provided with new floor covering. There are otherwise excellent standards of hygiene and cleanliness. EVIDENCE: A tour took place of the entire building. The majority of bedrooms were seen, apart from bedrooms where some service users were sleeping. Churchfields Court is purpose built, yet is able to provide a homely atmosphere, with 2 separate lounges and a Quiet Room, in addition to 2 dining rooms. It was noted that some doors were propped open. If, for the convenience of the Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 19 service user, a door is to be kept open, an automatic closure device must be fitted. Several doors were found to close violently and these must be checked and adjusted. All bedrooms have an en suite toilet and wash hand basin. There are 3 communal bathrooms and 1 communal shower room in the home. Currently the first floor bathroom (the only one on this floor) is not used, as the “Jacuzzi” style bath is not popular with the service users. With this bathroom out of action, there is no bathroom on the first floor and all service users who have rooms on this floor have to go down in the lift to take a bath. It also means that there are insufficient bathing facilities for the 37 service users. This is unsatisfactory. The service users must be consulted and a suitable bathroom provided on the first floor. A strong odour was noted in 3 bedrooms. The Registered Manager was asked to ensure that carpets in these rooms are shampooed in the first instance and that if the odour persists, the carpets must be replaced. The provision of new floor covering must be discussed with the service user and their relatives. Apart from the rooms noted above, the premises were found to be clean and hygienic. There were no odours (apart from those noted in individual bedrooms, above). The laundry was in good order and colour coded baskets have now been provided for the clothes of each individual service user. Health and safety procedures are displayed in the laundry and there are hand washing facilities for staff. The washing machine has a sluicing facility. 8 service users returned questionnaires and all 8 said that the home was “always” fresh and clean. Service users spoken to confirmed this and made complimentary remarks about the cleanliness of the home. One person said that the home had “wonderful cleaners”. Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 20 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 and 30. The overall outcome for this group of Standards is judged to be Adequate. The Registered Persons must take care to ensure that there are always enough staff on duty to meet the needs of the service users. There have been occasions recently when the numbers of staff mean that they are at the limit of providing safe care to their more dependent service users. Generally there are good opportunities for training, but the home must ensure that copies of certificates are available in staff files so that this can be verified. Recruitment procedures are sound, but the home must obtain a full employment history of all prospective staff. The induction process has improved since this standard was last inspected. All new starters must have a training and development assessment in their file. Service users, both in their returned questionnaires and in person said that they were looked after by very caring staff. EVIDENCE: Rotas provided to the Commission prior to the inspection showed that there are usually 4 care staff on duty from 8.00 a.m. until 9.00 p.m. This is in addition to the Manager, whose hours are Supernumerary. Overnight there are two waking carers on duty. During this time there is a senior member of staff available “On Call”, in the event of an emergency. At the time of the inspection the Manager was working “on the floor”, this having been necessitated by current staff shortages. The Manager stated that this was not the usual case, but that some people were off sick and others on holiday. In addition to the care staff, domestic and cooking staff are employed. The cook Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 21 is on duty from 8.30 a.m. to 3.00 p.m., so the tea-time meal is served by the care staff (sandwiches having been prepared earlier by the cook). On 2 days a week a cooked tea is served and on these occasions the cook stays on until 5.00 p.m. These staffing levels are at the minimum acceptable level only and the home must ensure that at all times there are sufficient staff on duty to meet the needs of the service users. During the day-time there must always be four care staff on duty. The manager’s hours must be supernumerary. In their returned surveys, 7 service users said that staff were “always” available when they needed them. 2 said that staff were “usually” available. Some service users remarked that there didn’t always seem to be enough staff on duty. One person felt that as the dependency levels of the service users had increased, there had been no increase in the numbers of staff. One service user felt that sometimes they were “rushed”, something that had never happened in the past. The Manager states that 10 of the 16 staff have the NVQ2 or above. Copies of NVQ certificates were seen on some files, but some were missing. The Manager must ensure that copies of training certificates are available on all individual staff files. For the assessment of training in mandatory health and safety areas, see Standard 38. The staff files of new recruits were seen. All had application forms on file, an interview questionnaire, 2 written references and confirmation of satisfactory CRB and POVA checks. The home’s Application Form needs to be revised, as currently it does not require a full employment history. All staff have been given copies of the General Social Care Council Code of Conduct. Evidence was seen in some staff files of thorough induction procedures to meet Skills for Care specifications. In their first 4 days new staff go through an induction period. Full induction training is completed within 3 months of their appointment. All new starters must have an individual training and development assessment in their files. Staff receive at least 3 days paid training per year and there is a Training Budget in place. Service users spoken to during the inspection were full of praise for the staff. They said: “They are hard working girls.” “The staff are very helpful.” “They are so kind and would do anything if you ask them.” “Very caring people.” Relatives who were visiting at the time of the inspection were also very complimentary about the staff, who they said were always “friendly and welcoming”. Staff spoken to were enthusiastic and clearly enjoyed their work. There was mention, however, of some difficulties for staff when there are shortages. Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 22 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 and 38. The overall outcome for this group of Standards is judged to be Good. There is a strong Manager in place who is well supported by the Deputy and staff team. Service users benefit from living in a home which is well managed and administered. The views of service users are obtained and acted upon. Service users’ financial interests are safeguarded by the home’s policies and procedures. The health, safety and welfare of service users and staff are promoted. EVIDENCE: The Registered Manager has worked at the home since 2000. She was formerly the Deputy Manager and was appointed Manager in May 2005. The Manager holds a relevant Diploma and the NVQ4 qualification. She is well supported by her Deputy Manager. The Manager continues to update her skills Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 23 by regularly taking part in training. She is currently undertaking the Safe Handling of Medicines training. Questionnaires have been sent to service users in order to obtain their views about the home. 25 service users took part and about 25 of them responded in writing. Relatives’ views are also sought. The home have analysed the findings from these questionnaires and they are on display on the notice board. It is recommended that other stakeholders, such as social workers, district nurses and G.P.s be asked to complete questionnaires. Service users’ meetings are regularly held. The last minutes were seen and it was noted that 18 service users attended. Staff meetings are regularly held and there is a separate meeting for night staff. The Registered Person visits the home regularly. He must ensure that he writes a monthly report on the conduct of the home and that a copy of this report is forwarded to the Commission. The home takes charge of some monies on behalf of 12 service users. 1 service user is subject to Appointeeship, the Appointee being the Local Authority. A sample of the monies and accompanying records were seen at the inspection and all were in order. It is recommended that when the money being held reaches a certain amount, that the service user is requested to open a Bank or Building Society account. It may be that an Advocate could be involved in such cases. All monies are kept securely. The home’s training schedule shows that staff are regularly trained in the mandatory health and safety areas of food hygiene, moving and handling, first aid, fire safety and infection control. As stated in Standard 28, above, the home must ensure that certificates verifying this training are kept in staff files. The home has a Fire Risk Assessment in place, which is reviewed every 6 months. Fire safety checks take place at regular intervals. Records show that the fire alarms and emergency lights are tested each week and that a fire drill takes place every 6 months. Up to date Maintenance certificates were also seen for the gas safety (05.08.06.), Electrical systems (2005), Lift (05.06), hoists (Sept. 05) and PAT testing (January 2006). The wheelchairs were checked and maintained in May 2006. Water temperatures at outlets accessible to service users are checked regularly and records retained. All hazardous substances used in the home are securely locked and an analysis is kept of all the products used. The Registered Manager, in her questionnaire submitted to the Commission, has stated that all policies and procedures with regard to health and safety are in place. New staff receive induction training in safe working practice topics (see Standard 30). The home complies with Regulation 37 of the Care Homes Regulations by informing the CSCI of any serious event affecting a service user. Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 24 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 X X X HEALTH AND PERSONAL CARE Standard No Score 7 3 8 3 9 3 10 3 11 X DAILY LIFE AND SOCIAL ACTIVITIES Standard No Score 12 4 13 3 14 3 15 3 COMPLAINTS AND PROTECTION Standard No Score 16 3 17 X 18 2 2 X 2 X X 2 X 2 STAFFING Standard No Score 27 2 28 2 29 2 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score 4 X 2 X 3 X X 3 Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 25 Are there any outstanding requirements from the last inspection? No. 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 OP18 Regulation 12(1)(a) Requirement The home’s Adult Protection Procedure must be revised so that it is in line with the Sandwell Social Services Procedure and the Department of Health document, “No Secrets”. Copies of both these documents must be obtained by the home. Fire doors must not be wedged open. If, for the convenience of the service user, the door is to be kept open, an automatic closure device must be fitted. All fire doors must be checked and adjusted, as some close violently at present. There must be sufficient assisted baths provided for the service users. A suitable assisted bath must be provided on the first floor. Where there are odours in rooms, carpets must be cleaned or replaced as necessary. The Registered Person must ensure that at all times there are sufficient staff on duty to meet the needs of the service users. DS0000004842.V305660.R01.S.doc Timescale for action 31/08/06 2. OP19 23(4) 30/09/06 3. OP21 23(2)(j) 31/12/06 4. 5. OP26 OP27 16(2)(k) 18(1)(a) 30/08/06 30/08/06 Churchfield Court Version 5.2 Page 26 6. 7. 8. 9. OP28 OP29 OP30 OP33 Schedule 2.4 19(1) 18(1)(c) 26 Copies of training certificates must be available on individual staff files. Application forms must contain a full employment history. All staff must have an individual training and development assessment and profile. The Registered Person must visit the home at least once a month and prepare a report on the conduct of the home. A copy of this report must be forwarded to the Commission. 30/09/06 30/08/06 30/09/06 30/08/06 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 OP8 Good Practice Recommendations It is recommended that the home produce a brief “Pen Picture” of each service user, which gives details of their personal history as well as information of the contact and support they can anticipate from family and friends when they move to the home. It is recommended that Care Plans contain more detail on the process of care, i.e. how the service user likes the particular intervention to be carried out. It is further recommended that following the monthly review, the care plan is signed and dated by the reviewer to confirm that the review has taken place. It is recommended that the home’s kitchen be provided with a mincer or liquidiser. It is recommended that when dried foods are de-canted, the date of opening and the “best before” date be noted on the container. 2. OP8 3. OP15 Churchfield Court DS0000004842.V305660.R01.S.doc Version 5.2 Page 27 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.V305660.R01.S.doc Version 5.2 Page 28 - 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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