Inspection on 12/10/05 for Churchfields

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 Adequate. 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 no outstanding requirements from the previous inspection report, but made 5 statutory requirements (actions the home must comply with) as a result of this inspection.

Other inspections for this house

Churchfields 16/05/07

Churchfields 15/08/06

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Sun Court Nursing Home

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Paradise Lodge

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Upaya Ananda

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

CARE HOME ADULTS 18-65 Churchfields Avenue Road Witham Essex CM8 2DT Lead Inspector Brian Bailey Unannounced Inspection 12th October 2005 10:00 Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 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 Churchfields DS0000063439.V256359.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 Adults 18-65. 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. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 3 SERVICE INFORMATION Name of service Churchfields Address Avenue Road Witham Essex CM8 2DT 01376 521553 01376 521554 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) Active Care Partnerships (Churchfields) Ltd Mrs Stella Elizabeth Harrington-Keeton Care Home 34 Category(ies) of Learning disability (34), Learning disability over registration, with number 65 years of age (5), Physical disability (11) of places Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 4 SERVICE INFORMATION Conditions of registration: 1. 2. 3. 4. 5. Persons of either sex, under the age of 65 years, who require care by reason of a learning disability (not to exceed 34 persons) Five named people, aged 65 years and over, who require care by reason of a learning disability Eleven named people, under the age of 65 years, who require care by reason of a learning disability and who also have a physical disability The total number of service users accommodated in the home must not exceed 34 persons The one service user in the room that does not meet the space requirements of the National Minimim Standards for people with physical disabilities may continue to use that room. Once they vacate the room it may not be used by a person with a physical disability, the details of which were made known to the Commission 11th May 2005 Date of last inspection Brief Description of the Service: Churchfields is a care home providing personal care and accommodation for a total of 34 adults with learning disabilities, including 11 people with physical disabilities and 5 people over 65 years of age. Active Care Partnerships Ltd privately owns the home. The manager is Stella Harrington-Keeton. Churchfields is situated in a residential area of Witham, Essex and is within easy reach of local shops, railway station, pubs, library, post office and other amenities. The home was opened in 1998 and consists of 11 separate self-contained accommodation units ranging from single bedroom bungalows to 6 bedroom flats. Accommodation on the first floor is accessed by a passenger lift. All the home’s bedrooms are for single occupancy. The home has private grounds and car parking facilities. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 5 SUMMARY This is an overview of what the inspector found during the inspection. This unannounced inspection took place on 12th October 2005 from 10.00am until 6.25pm. This was the second inspection of Churchfields in the 2005/6inspection year. The focus of this visit was to check on the progress the manager had made on meeting the requirements made at the last inspection and to spend time in St. Gerald’s and Croft Units with staff and residents. The inspection included a tour of most of the units, when the majority of staff and residents were seen and spoken with, the day centre, care records and medication were checked and information was gathered on staff training. What the service does well: What has improved since the last inspection? A manager has been appointed and registered by CSCI. A team leader and new staff have been appointed, which will lessen the need for agency staff to be employed. The manager had implemented a programme of change to improve the facilities within the units, to develop the day centre, review procedures and residents participation in the running of the home, promote residents independence and reassess the Quality Assurance system. Residents and staff spoken with felt that there were now more opportunities to get out into the community. A revised Statement of Purpose has been produced that is informative and well laid out. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 6 Decoration and furnishings are being improved and those areas are starting to look more welcoming and homely. New bathing facilities were in the process of being installed and some new furniture and carpets were on order. The grounds are well maintained and an enclosed garden area enabled living in St. Peters and St. Elizabeth to have free access to the area. 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. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 7 DETAILS OF INSPECTOR FINDINGS CONTENTS Choice of Home (Standards 1–5) Individual Needs and Choices (Standards 6-10) Lifestyle (Standards 11-17) Personal and Healthcare Support (Standards 18-21) Concerns, Complaints and Protection (Standards 22-23) Environment (Standards 24-30) Staffing (Standards 31-36) Conduct and Management of the Home (Standards 37 – 43) Scoring of Outcomes Statutory Requirements Identified During the Inspection Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 8 Choice of Home The intended outcomes for Standards 1 – 5 are: 1. 2. 3. 4. 5. Prospective service users have the information they need to make an informed choice about where to live. Prospective users’ individual aspirations and needs are assessed. Prospective service users know that the home that they will choose will meet their needs and aspirations. Prospective service users have an opportunity to visit and to “test drive” the home. Each service user has an individual written contract or statement of terms and conditions with the home. The Commission consider Standard 2 the key standard to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 1, 2 and 3 The home’s statement of purpose and residents’ guide provide residents and prospective residents with up to date information. Pre-admission assessment information is obtained that enable the home to determine whether it can meet the needs of prospective residents. EVIDENCE: The home has an informative Statement of Purpose that had been revised to reflect the change of organisation and manager and meets the requirements of the National Minimum Standards. The admission procedure is sufficiently clear to guide staff on the actions to be taken to ensure that new residents needs are properly assessed and planned for. Evidence was available to show that the recent admission of a resident had been well planned. Opportunities were provided for the resident to visit the home on several occasions to meet the staff and other residents and for staff to visit the resident in their own setting. Detailed assessments and information were obtained and the manager had completed the homes own pre admission forms. The information gathered during this process had enabled the home to be confident that the prospective residents needs could be met at Churchfields. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 9 Individual Needs and Choices The intended outcomes for Standards 6 – 10 are: 6. 7. 8. 9. 10. Service users know their assessed and changing needs and personal goals are reflected in their individual Plan. Service users make decisions about their lives with assistance as needed. Service users are consulted on, and participate in, all aspects of life in the home. Service users are supported to take risks as part of an independent lifestyle. Service users know that information about them is handled appropriately, and that their confidences are kept. The Commission considers Standards 6, 7 and 9 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 6 and 8. Residents’ care needs are well documented and individual risk assessments are in place. EVIDENCE: Individual care plans are available and these are retained in each unit. Care plans were sampled checked in Croft and St. Gerald’s Units. These were detailed and consistent in layout. Assessments were available for moving and handling together with protocols for particular care needs and records of regular weight checks and attendance with health care professionals and any infringements of rights. From discussion and observation of residents, it was evident that staff encourage service users to participate in the day to day running of the units and empower them to make to decisions whenever possible. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 10 Lifestyle The intended outcomes for Standards 11 - 17 are: 11. 12. 13. 14. 15. 16. 17. Service users have opportunities for personal development. Service users are able to take part in age, peer and culturally appropriate activities. Service users are part of the local community. Service users engage in appropriate leisure activities. Service users have appropriate personal, family and sexual relationships. Service users’ rights are respected and responsibilities recognised in their daily lives. Service users are offered a healthy diet and enjoy their meals and mealtimes. The Commission considers Standards 12, 13, 15, 16 and 17 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 11, 12 and 16. Residents undertake an interesting and stimulating range of activities that are appropriate to the people involved EVIDENCE: None of the residents seen were in any form of paid or voluntary employment. Residents are able to attend community based educational facilities and on-site day care activity classes. The programme shows that a wide range of sessions is provided each weekday that vary from communication skills, computers and cultural studies as well as leisure activities. A music session was in progress during the inspection, which was clearly enjoyed by all those in attendance. A resident described the varied events that they can participate in and liked the staff. Progress had been made in enabling more residents to attend local colleges. It was evident from observation that residents have unrestricted access to all communal areas of the home and grounds Residents spoke of liking to take trips to the local shops for food, personal shopping and visiting the hairdressers and cafes. A mini bus is available for trips out and was seen to be in use throughout the day. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 11 Staff were observed to interact well with residents and had clearly established a good rapport. Residents are able to keep a pet with the agreement of the home. One resident has a cat although some staff expressed concerns about hygiene issues. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 12 Personal and Healthcare Support The intended outcomes for Standards 18 - 21 are: 18. 19. 20. 21. Service users receive personal support in the way they prefer and require. Service users’ physical and emotional health needs are met. Service users retain, administer and control their own medication where appropriate, and are protected by the home’s policies and procedures for dealing with medicines. The ageing, illness and death of a service user are handled with respect and as the individual would wish. The Commission considers Standards 18, 19, and 20 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 18, 19 and 20. Residents’ health care needs are met appropriately but errors in the administration of medication may place residents at risk. EVIDENCE: From observation and discussion with staff and residents, it was evident that residents were provided with personal support and care in a manner, which maximised their independence, privacy and dignity. Various aids were available for those who needed them. A key worker system was in place. Service users confirmed that staff were kind and treated them with respect and dignity. All service users observed had clearly been enabled to maintain their hair, skin and nails in good condition. Service users contribute to staff recruitment. It was evident that aids and equipment were available for service users in order to maximise their independence The home uses a monitored dosage system for the administration of medication. All medication is kept in each of the units. New medication storage cabinets were in the process of being used. Medication administration records sheets on two units were checked, these were up to date although it was noted in St. Gerald’s, that there was no signature against an item of medication to indicate whether it had been administered, forgotten or refused. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 13 Concerns, Complaints and Protection The intended outcomes for Standards 22 – 23 are: 22. 23. Service users feel their views are listened to and acted on. Service users are protected from abuse, neglect and self-harm. The Commission considers Standards 22, and 23 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 22 and 23. Not all staff employed have completed training on the protection of vulnerable adults from abuse and therefore residents may be placed at risk until this is achieved. EVIDENCE: The home has a policy on the protection of vulnerable adults from abuse and a whistle blowing policy. Since the last inspection, many of the staff have received training on understanding abuse, but the records showed that there are still a number of staff that have not yet been able to attend. Staff spoken to confirmed they had been trained and they had an understanding of what constitutes abuse. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 14 Environment The intended outcomes for Standards 24 – 30 are: 24. 25. 26. 27. 28. 29. 30. Service users live in a homely, comfortable and safe environment. Service users’ bedrooms suit their needs and lifestyles. Service users’ bedrooms promote their independence. Service users’ toilets and bathrooms provide sufficient privacy and meet their individual needs. Shared spaces complement and supplement service users’ individual rooms. Service users have the specialist equipment they require to maximise their independence. The home is clean and hygienic. The Commission considers Standards 24, and 30 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 24, 27, 29 and 30. A comfortable and safe standard of accommodation is provided for the residents although all will benefit when the programme of improvements is completed. EVIDENCE: A programme of redecoration and refurbishment has started to improve the appearance of several units and work is still in progress on issues such as improvements to bathing facilities. Odour control was poor in two rooms in St. Gerald’s but the manager was aware of the problem and had plans to provide new floor covering. Ventilation was poor in St. Paul’s and St. Catherine’s Units despite the provision of fans. The lounge carpet in St. Peter’s was badly marked and according to the manager is to be replaced. Doors and doorframes in the Croft are damaged and the lounge looked rather dark and in need of brightening up. The grounds were much improved and looked neat and tidy. The kitchens in each of the units seen were of a good standard of cleanliness and tidy. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 15 Staffing The intended outcomes for Standards 31 – 36 are: 31. 32. 33. 34. 35. 36. Service users benefit from clarity of staff roles and responsibilities. Service users are supported by competent and qualified staff. Service users are supported by an effective staff team. Service users are supported and protected by the home’s recruitment policy and practices. Service users’ individual and joint needs are met by appropriately trained staff. Service users benefit from well supported and supervised staff. The Commission considers Standards 32, 34 and 35 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 32, 33, 35 and 36. Residents receive care and support from a well-motivated staff team that are employed in sufficient numbers. The home has been successful in some aspects of training although residents will benefit when all staff are trained in health and safety matters and further specialist training courses are provided. EVIDENCE: Staff training is given a high priority by the home. Training records showed that over 50 of the staff had obtained a National Vocational Qualification at level 2, which meets the National Minimum Standards target for this to be achieved by 31/12/05. Ongoing training is provided on a range of topics that has included epilepsy, medication and the protection of vulnerable adults from abuse and the basics of understanding and supporting adults with learning disabilities. Most staff had received some Health and Safety training although the records showed that there are a few staff that still require fire training, food hygiene, infection control and first aid. It was evident from discussions with staff that they are experienced and have acquired a great deal of knowledge about the residents they support. They were aware of their individual likes and dislikes and of the guidance in care plans. Staff were observed to have established a good rapport with residents and were relaxed and friendly. Residents appeared at ease in the company of staff. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 16 Staff rosters were available that showed that staffing levels were consistent and a designated senior member of staff is on duty on all shifts. The manager has been successful in recruiting some new staff, some of whom have an NVQ at level 2. The staff team reflects the gender composition of residents. Not all staff are receiving formal supervision at regular intervals. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 17 Conduct and Management of the Home The intended outcomes for Standards 37 – 43 are: 37. 38. 39. 40. 41. 42. 43. Service users benefit from a well run home. Service users benefit from the ethos, leadership and management approach of the home. Service users are confident their views underpin all self-monitoring, review and development by the home. Service users’ rights and best interests are safeguarded by the home’s policies and procedures. 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 are promoted and protected. Service users benefit from competent and accountable management of the service. The Commission considers Standards 37, 39, and 42 the key standards to be inspected at least once during a 12 month period. JUDGEMENT – we looked at outcomes for the following standard(s): 37, 38 and 39. Residents have the benefit of a safe and secure setting and that the manager is committed to providing a quality care service. However, without a system for self-evaluation in use and an annual review, residents are less able to influence services and standards. EVIDENCE: The manager, Stella Harrington-Keeton, commenced her duties in May 2005 and was registered by CSCI in September 2005. Stella has experience of working with adults with learning disabilities and has a NVQ 4 in care and the Registered Managers Award. The home is going through a wide-ranging programme of change that includes a review of current procedures and how the staff support residents. There has been an internal reorganisation that has impacted on some residents and it was evident that a few staff were finding the changes difficult to accept. However, residents and the majority of staff were positive about the home and the changes being made. Staff spoken to considered they were well supported and were always able to obtain assistance and guidance when required. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 18 The home has a Quality Assurance system in place but has not sought via a questionnaire survey the views of residents, relatives, staff and other interested people in recent months, but the manager stated that a revaluation of the system would take place in the near future. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 19 SCORING OF OUTCOMES This page summarises the assessment of the extent to which the National Minimum Standards for Care Homes for Adults 18-65 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 CONCERNS AND COMPLAINTS Standard No 1 2 3 4 5 Score 3 3 3 X X Standard No 22 23 Score X 2 ENVIRONMENT INDIVIDUAL NEEDS AND CHOICES Standard No 6 7 8 9 10 Score 3 X 3 X X Standard No 24 25 26 27 28 29 30 STAFFING Score 2 X X 3 X 3 2 LIFESTYLES Standard No Score 11 3 12 3 13 X 14 X 15 X 16 3 17 Standard No 31 32 33 34 35 36 Score X 3 3 X 3 2 CONDUCT AND MANAGEMENT OF THE HOME X PERSONAL AND HEALTHCARE SUPPORT Standard No 18 19 20 21 Churchfields Score 3 3 2 X Standard No 37 38 39 40 41 42 43 Score 3 3 2 X X X X DS0000063439.V256359.R01.S.doc Version 5.0 Page 20 No 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 2 Standard YA20 YA23 Regulation 13 13 Requirement All medication administered to residents must be accurately recorded. All staff must attend training on the protection of vulnerable adults from abuse and understand the abuse procedures. (Timescale of 1/10/05 not met) The lounge carpet in St. Peters, and a bedroom carpet in St. Gerald’s need replacing. Doors and doorframes in Croft must be redecorated. The ventilation in St Paul’s and St Catherine’s must be improved. The manager must complete a Quality Assurance system survey that includes residents, relatives and all other interested persons. Timescale for action 01/12/05 01/01/06 3 YA24 23 01/01/06 4 5 YA24 YA39 23 24 01/03/06 01/02/06 RECOMMENDATIONS These recommendations relate to National Minimum Standards and are seen as good practice for the Registered Provider/s to consider carrying out. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 21 No. 1 Refer to Standard YA36 Good Practice Recommendations All staff should receive supervision six times a year as a minimum. Churchfields DS0000063439.V256359.R01.S.doc Version 5.0 Page 22 Commission for Social Care Inspection Colchester Local Office 1st Floor, Fairfax House Causton Road Colchester Essex CO1 1RJ 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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