Inspection on 09/05/05 for Churchfield Court

This inspection was carried out on 9th May 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 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 Court 18/10/07

Churchfield Court 02/08/06

Churchfield Court 12/10/05

Churchfield Court 10/11/04

Churchfield Court 15/06/04

Churchfield Court 11/02/04

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Maple Lodge

Heathlands

Aston Court Nursing Home

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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 9th May 2005 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 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 E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 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 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 Care Home 37 Category(ies) of Old age, not falling within any other category. registration, with number of places Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 Page 4 SERVICE INFORMATION Conditions of registration: None. Date of last inspection 10th November 2004 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 aceess to a transport networks. The home was purpose built for the care of the elderly. 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 toliets and wash basins. Communual space includes 3 lounges and 2 dining rooms. Sufficent bath and shower facilities are also available. Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. During the inspection 16 residents and 4 relatives, 7 staff members and the acting manager were spoken with individually. The buildings were toured and the kitchen and laundry room inspected. Additionally care plans, staff files and the medication records were examined. 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 E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 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 Standards Statutory Requirements Identified During the Inspection Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 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 standard(s) 1,2,3,4&5 The home now has good admission procedures in place to ensure that resident’s needs are fully assessed and can be met by the home. The home has also ensured that information about the services offered is available and up to date. EVIDENCE: Case notes were examined for three residents including one who had only recently moved in. In the most recent notes a comprehensive assessment had been undertaken, by the manager, in their current environment. Information had also been received from other services involved in their care. Following the assessment a letter had been sent confirming that their needs can be met and they were invited to visit the home before moving in for a four-week trial. Information about the home was found available in reception including the homes ‘statement of purpose’ and ‘service user guide’ to help. Contracts or a statement of terms and conditions had also been completed and signed by the resident or their representative. Intermediate care is not provided (standard 6) Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 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 standard(s) 7,8,9&10 The standard of care plans is very good and it is evident that a lot of hard work has gone into making these improvements. The evidence shows that residents are receiving an excellent standard of care and their needs are being met. EVIDENCE: The three care plans examined were found to be accurate, up to date, and easy to read. A new format has been introduced which showed exactly what support was was needed from care staff to meet residents assessed needs. These had then been signed by the resident or their representative. All health care needs had been recorded, monitored and further appointments made. The medication records were examined and found to be complete and in good order. Copies of the prescriptions had been kept and were checked against the orders received from the chemist. The only outstanding requirement not met was to ensure residents had given written consent that staff can administer their medication or to complete a risk assessment if they are doing it themselves. Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 Page 9 Residents for whom it was identified at the last inspection had been admitted outside the homes registration criteria, for example someone diagnosed with dementia have been re-assessed, and if needed are or have been, sought appropriate alternative accommodation. The home will endeavour to work with the Commission to ensure residents whose needs change can remain living at Churchfield Court. Residents and relatives spoken to during the day all praised the level of care they received. Comments included ‘all the staff work very hard’ ‘they bring you a cup of tea and a sandwich in the night if you want one’ ‘it’s very nice hear’ and ‘we are thrilled about the home’. It was also shown by correspondence received that relatives whose parents passed away that they were comforted by the care and treatment they had received. Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 Page 10 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 standard(s) Standards were not fully assessed on this occasion. EVIDENCE: Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 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 standard(s) Standards were not fully assessed on this occasion. EVIDENCE: Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 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 standard(s) 19,21,22,25&26 Although purpose built, Churchfield Court maintains a homely and friendly atmosphere. All areas of the home were comfortable and furnished to a high standard. EVIDENCE: A tour of the building showed that all communal areas were maintained, decorated with no repairs outstanding. Bathroom and shower facilities had the appropriate adaptations fitted including raised toilet seat, handrails and hoists which had been serviced. The kitchen was found to be clean and tidy with checks being made to ensure fridge, freezer and cooked meat temperatures are maintained. Some items of food were found out of date however action was immediately taken and a system introduced to ensure daily checks are made. The laundry room was appropriate for the size of the building. Health and safety procedures were displayed and staff hand washing facilities were available. Coloured baskets must be introduced and new procedure implemented to ensure laundry is not cross contaminated. Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 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 considers Standards 27, 29, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) 27,29,29&30 Staff recruitment procedures are very good and excellent work has been done to ensure all staff are aware of the homes policies and procedures and their responsibilities around the home. Induction for new staff however is not satisfactory and training is not provided soon enough after starting. EVIDENCE: On the day of the inspection there was a shift leader, senior care, and two care assistants in addition to the manager hours. Domestic cover is provided over seven days with either one or two people on duty. Kitchen hours are also covered every day from morning till afternoon. Staff daily duties have now been broken down into 3 groups, which are colour co-ordinated and include activity organiser and kitchen assistant tasks. Due to the size of the home staff levels must be regularly reviewed to ensure sufficient cover is provided at all times. Individual training plans and regular supervision including daily meetings to go through homes policies and procedures have been introduced. It is clear however that there are gaps in the training provided, especially for new workers who may not have appropriate experience to carry out their full range of duties; manual handling for example. Additionally the home must introduce more detailed induction procedures, which insure training is provided to the National Training Organisation workforce targets within six weeks. Additionally more time must be available to shadow existing staff in addition to normal staffing hours provided. Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 Page 14 All Four staff files were inspected including the most recent employee. recruitment procedures had been followed including ensuring receipt of references, proof of identification and police record checks. New procedures had also been introduced to ensure records are kept of the interview process and all staff have a contract before starting work. Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 Page 15 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 33, 35 and 38 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for standard(s) Standards were not fully assessed on this occasion. EVIDENCE: Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 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 ENVIRONMENT Standard No 1 2 3 4 5 6 Score Standard No 19 20 21 22 23 24 25 26 Score 3 3 3 3 3 N/A 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 x 13 x 14 x 15 x COMPLAINTS AND PROTECTION 3 x 3 3 x x 3 2 STAFFING Standard No Score 27 3 28 2 29 3 30 2 MANAGEMENT AND ADMINISTRATION Standard No 31 32 33 34 35 36 37 38 Score Standard No 16 17 18 Score x x x x x x x x x x x Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 Page 17 yes 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 9 Regulation 12,13&18 Requirement All service users must give written concent that they have agreed to have their medication administered or if doing this themselves do so following a risk assessment. This is an outstanding requirement. Induction procedures must be implemented to meet NTO specifications within the first 6 weeks. New staff not completing a foundation course must be enrolled on a NVQ level 2 training course. All new staff without must not be included in the normal staffing hours dependeing on experience, for at least 3 to 5 days to allow for shadowing other employees and to meet induction training requirements. All gaps identified in the training plans must be met. Colour co-ordinated baskets must be used for both clean and dirty laundry and the procedure updated. Timescale for action 01/08/05 2. 30 18&19 01/08/05 3. 38 12&13 01/08/05 Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 Page 18 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 Good Practice Recommendations Churchfield Court E55 S4842 Churchfiled Unannounced V224295 050505 Stage 4.doc Version 1.30 Page 19 Commission for Social Care Inspection Mucklow Office Park West Point Mucklow Hill Halesowen 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. 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